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Saturday
Aug082009

What Would You Do for an Epidural?

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Something that I have always wondered but have been too afraid to ask…

 

How many women don’t care about their birth as long as they get effective pain relief from an epidural?

 

Thankfully, PinkyRN wrote something today that saved me from putting the topic on the table:

The cause of that is not the epidural the woman chose. However, I have one caveat, I think the woman needs to be in active labor before an epidural is placed. Now this is a huge fight many days. And many women just don’t care how the baby comes out. They just want an epidural even though they are long thick and closed….I cannot talk them out of it. I try to give them the information they need to make this choice.

But really when they are in that pain, they don’t give a flying rats a$$ about medical literature. Sorry I digress….Early epidurals is a subject for another day. However very early epidurals, like the woman’s cervix is closed, is a big concern of mine that they will not progress to anywhere but the big room for the C-section. Now if the patient is OK with that, I guess it is her decision to make.

 

The reason I held off on asking is because I would get really, really disappointed if I got a slew of mother-bashing comments about epidurals á la Strollerderby commenter Crunchy Mama, who wrote the following about epidurals and the women who get them:

Women who get epidurals are cowards. Yes, having a baby hurts. Deal with it. In the process, you might discover that you can actually deal with just about anything. A good skill for a mother to have.

Yes, I know whereof I speak. I had all three of my children without taking so much as a Tylenol, and I had them at home, to boot.

Facing danger and emerging triumphant is character building, and character is something this country could use a little more of. Whiners, boo-hoo’ers, victims, wimps… we have plenty of those.

Obviously, I am not referring to anyone with a life threatening complication. Giving birth can and does kill mothers and babies. But as far as I know being a candyass doesn’t qualify as a life threatening medical emergency.

 

On Stork Stories, the anonymous super-nurse recounts how in the seventies when she began her work in L&D, it was common for women to request (or agree to) general anesthesia in labor and common for the hospital staff to oblige:

Many of the mom’s in labor opted to be “put under” which didn’t happened until they were moved to the delivery room, crowning. Seem so ridiculous now…I mean it’s just about over!

 

My question is mostly for care providers and for women discussing their own experiences in the hospital. Discussing the experiences of others is fine if judgment is withheld and I appreciate your cooperation on this.

 

Is it common for women to hop right onto the bed and say something like I don’t really care what happens as long as we both come out alive and I don’t have to feel a thing?

 

And as a care provider, how do you react to this?

 

Photo credit (unaltered)

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Reader Comments (30)

I attempted a VBAC last month, and I had an epidural at around 7 cm (and around hour 37 of active labor). It was ineffective, as I could feel everything on my left side, and later feel everything.

The funny part is, it gave me someone to curse during hour 40 after it was determined that I needed a c-section. Every contraction I was all, "... And why couldn't the G/D anesthesiologist give me an epidural that worked?! I'd better not have to pay for this. I TOLD you I can feel everything, dammit!" Thanks, Dr. Anesthesiologist, for being my scapegoat.

Luckly his shift had ended, or I would've cursed AT him when he had to come fix it for the section.

August 8, 2009 | Unregistered CommenterEG

This should be sung to the tune of "What Should We Do With a Drunken Sailor".

I'm curious to hear people's thoughts too! The topic of epidurals, and the fact that women need to know that they're NOT necessarily guaranteed (nor recommended, actually) upon admittance, was recently addressed in a great post by Reality Rounds, which I'm sure you saw. (And I added some thoughts on that in my response.)

I hope Nursing Birth in particular weighs in. Rixa too!

August 8, 2009 | Unregistered CommenterDou-la-la

EG,

I'm sure even if you had given him an earful during c/s prep, it wouldn't have been anything he'd never heard before.

That pretty much stinks to go through getting the epidural and not even have it work. And ESPECIALLY after being labor for a day and a half when you're thinking you're finally going to get a break or maybe some sleep. I sorry to hear that, but I'm glad you got to use the anesthesiologist as a focal point while in pain! :)

Jill

August 8, 2009 | Registered CommenterJill

See, this is when I throw my hands into the air and think that the problem of our barbaric L&D practices is just too big. But then I remember how you eat an elephant, and I go back to my doula training. One bite at a time. One baby at a time. One woman at a time.

*hunkers down*

August 8, 2009 | Unregistered CommenterLaura Grace

Maybe it's just asking the wrong question, though. Let's look at it this way:

Would women, if they could, choose a completely painless birth that did not expose them or their baby to additional risks or pain and allowed them to actually enjoy the experience itself?

Well, yes, DUH. But, that's not what an epidural offers. What women aren't told is:

--an epidural offers some relief, IF it works, IF it's given at the right time, and EXCEPT for the fact that it increases your likelihood of c/sec or having to help the baby out BECAUSE it keeps you immobile. Which could give you a nightmareish experience/recovery that NEGATES all the good the epidural does.

When they used to put you under, they also used the forceps and sometimes tore the hell out of your body and hurt the baby. Which is why they don't do that anymore, but c/sec you instead. Which leads right back to a hell of a recovery.

In other words, "women" are not making an informed choice about epidurals, a large percentage of the time. And many of them are completely blindsided if it doesn't work/causes other problems.

My personal feeling is, yeah, if we really had a miracle drug that preserved women's mobility in labor, had no side effects, and blocked all pain? Bring it on! But we do not have this drug, and women should know that up front.

August 8, 2009 | Unregistered Commenteremjaybee

I don't encounter "I want an epidural no matter what, right as soon as I want it, no matter what's going on" very often, actually. But, I don't attend clients I don't know, either - I only attend my own clients (or very occasionally my partner's) who have all had a good antenatal discussion of risks and benefits of epidurals. In fact, I remember reading the study that supposedly compared early and late epidurals (which actually compared early epidurals and early intrathecal followed by epidurals) and noticing that the average cervical dilation at first request for pain medication was 2 cms and being dumbfounded. I take care of a something like 60 labor clients a year and almost never hear a request for pain meds at 2 cms! I always discuss with clients before hand that epidurals can be a good tool for pain relief, but that it's best to start them in active labor, and then we talk about the risks of epidural (significant drop in blood pressure, spinal headache, long term back pain, slowing labor progress, need for augmentation, increased difficulty in pushing and increase in instrumental delivery, 4-fold risk of persitent posterior, and the risk that it won't work completely or partially). We then talk a lot about the non-drug methods of pain relief always available, and about using them instead of, or at least before the epidural (freedom of motion, water, birth balls, massage, being free to eat, drink, and move as you wish) Only about a third of my clients choose an epidural, and they arrive to L&D expecting to be in active labor before an epidural is started. Also, I don't do a lot of inductions, which may influence why I don't see such early requests for epidurals - I think in most normal labors it's uncommon for women to have unbearable pain that early in labor (not impossible of course, but unusual.) Induced labors often cause more pain earlier on, and since the prodromal or latent phase of an induced labor is often pretty long, women may have used up their coping skills before even getting to active labor.
I think most women, if given the opportunity to understand the risks and benefits of epidural anesthesia, make choices that benefit them and their babies. I think during labor is a bad time to do this educating, however! It needs to start much earlier, and be part of a long standing relationship between client and provider.
When I do face someone who is insistent on an epidural before active labor, I do what I can to educate them and help them understand why it's a good idea to wait, and the risks of starting an early epidural. If they really understand these risks, though, and really say they don't care what happens, then we call anesthesia for an epidural. It's pretty hard for me to deny pain relief to someone in pain who has no desire for the things I consider good outcomes - a normal birth, avoiding a cesarean, etc. I can really only call to mind one client who was so insistent - she'd also originally wanted an elective primary cesarean (something I'm not comfortable with) After the epidural at 2 cms, her labor turned in to the typical cascade of interventions, and she eventually had a cesarean for failure to progress, never making it past 4 cms. She was quite content with the outcome, although I was frustrated!

August 8, 2009 | Unregistered Commenterdoctorjen

My cousin says things like all she cares about is getting the epidural. She says she understands things like, "it might have higher risk of c-section" and other risks associated with epidurals. She also says she doesn't think that would happen to her. Her younger sister delivered with an epidural and she witnessed that birth so she thinks all births go like that. My younger cousin was fortunate to have an epidural and still have a vaginal delivery. Although she doesn't really remember much of her own birth experience. She also had breastfeeding troubles. My older cousin doesn't really seem to care. She does remark that she would do anything to breastfeed her child no matter what but I don't think she understands how hard it can be to establish a nursing relationship if that bond isn't made immediately. It isn't impossible, its just harder.She describes to me that she just doesn't want to feel all the pain. I can't get through to her that the pain isn't all that bad once you get the hang of it. She just doesn't want to hear it, she doesn't want to consider pain when there are drugs that take the pain away. She doesn't view birth as an experience, she views it as a terrible thing to go through before getting a baby at the end. It breaks my heart, but I know I can't do anything to change her mind or consider other options. I think women live in a culture of fear that all the see or experience is that birth is a terrible painful thing. I do think there is some residual "Eve suffering for her sins" mentality going on too. I think a lot of women think, "why should I suffer?" There are so few women that experience true natural birth that the story of how beautiful it is doesn't get told. I don't see depictions of normal birth on television or in movies. Rarely, natural birth is shown, but usually in the context of some archaic scene. Never do you see natural birth depicted in current times. As long as birth as depicted as a scary worse pain in your life experience, women will continue to ask for epidural regardless of the consequences.

August 8, 2009 | Unregistered CommenterClarissa Jarem

It is so unrealistic to assume you will feel nothing with an epidural. I am one of those "cowards" who had an epidural with both babies. I planned NCB with baby one, but that didn't work. Even with the epidural I felt like I was being ripped apart with each contraction. I was holding on and shaking the bed rails like a mad woman. The epidural was useless. I only had an epidural for about an hour with baby #2 and only felt pain during crowning.

I would never flame a woman for wanting an epidural like Crunchy Mama does. The risks and benefits need to be explained well before actual labor. With that said, unlike Dr. Jen, I do see patient after patient demanding an epidural the minute they enter the hospital. I work in a very diverse, inner city setting. How ethical is it to deny, or explain to death the rare risks of epidurals to the teenage mom, or the mom who is a victim of rape, or the mentally retarded mom, or the mom who suffered genital cutting in her country, or the mom who is just deathly afraid of pain? Have seen all these types of patients. Are they cowards, or victims of the "barbaric" L&D practices in this country because they were offered and received epidurals during labor, no matter what stage they were in?

August 8, 2009 | Unregistered CommenterReality Rounds

Reality Rounds, those are some important points. Thanks for the perspective.

And doctorjen, you sound like a really wonderful doctor.

August 8, 2009 | Unregistered CommenterDou-la-la

Reality Rounds, I agree - labor is not the time for extensive education (or, more likely, as the desperate laboring woman will see it - being argumentative and refusing wanted pain relief.) I don't argue with women in labor - we talk a lot before hand but I tell them - "If you ask me for pain medicine in labor, I won't be arguing with you. You know what's availabe, so I won't be asking YOU repeatedly if you want pain medince, but I assume if you ask me, you mean it."
I don't practice in the inner city, and the majority of my clients are Caucasian, but I do see a pretty full range of experience among my clients. I care for a lot of teens in my practice, do prenatal care and births for a local maternity home that has a lot of women with history of personal physical or sexual abuse as well as substance abuse, as well as care for more standard adult women with planned and wanted pregnancies. I still find that most of the clients I've cared for throughout pregnancy are not wanting an epidural at the first hint of labor, and are easily able to understand the risks/benefits of epidural anesthesia. My teen clients especially are likely to actually not want an epidural, which I thought was really odd when I first started in practice. I've found my teens do really well if allowed to move freely as they want, and allowed to call the shots on things like cervical exams and other interventions as much as possible. This has led to me catching some babies is really crazy ways (under the bed, on the bathroom floor, standing on the floor for a 6 foot tall 15 yr old who was standing on the bed, etc.) but my teen clients have seemed satisfied and proud of themselves.
I'm lucky to work in a setting that I think makes it easier for this to happen. I attend virtually all of my own clients, after having cared for them throughout pregnancy. My hospital provides 1 to 1 nursing for every labor. Our nurses are very skilled at labor support AND don't have to contend with policies that make women stay in bed.
But, if I was dealing with your clients, and meeting them for the first time in labor, and offering the usual comfort measures didn't immediately help, and they were still desperately wanting an epidural? I'd be calling anesthesia.
I've attended enough labors to know that my outside opinion about what pain someone should be able to cope with doens't count for diddly squat. You never know what a labor feels like to the woman actually laboring, and you never fully know what background experiences she's bringing with her that influence her wishes and coping skills. If someone needs/wants an epidural, and offering other comfort measures isn't helping, then we get the epidural and switch gears to minimizing its effects on labor (by encouraging mama to get some decent rest, by helping her change positions frequently, by letting her labor down and not be exhausting herself pushing before having any sensation, by helping her get upright to push, even with an epidural, and by making sure her baby goes straight to her arms at birth and has the opportunity to be skin to skin and to breastfeed if mom wishes before being disturbed by the medical team.)

August 8, 2009 | Unregistered Commenterdoctorjen
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