What Would You Do for an Epidural?
Saturday, August 8, 2009 at 10:15AM
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?
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.
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!
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
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*
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.
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!
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.
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?
Reality Rounds, those are some important points. Thanks for the perspective.
And doctorjen, you sound like a really wonderful doctor.
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.)
Good Morning! I love your blog.... I feel so passionate about this subject and its nice to come here are read.
My first sons birth went as follows - 1.break water, 2.jack up pit, 3.give epi, 4.no progression for hours and hours and hours. Finally made it to 10cm - push for 4 hours and end up with a section.
My doctor (an older man) was very open with me about other options besides an epi - we talked a lot during my visits about pain mgt. Dont' get me wrong - he isn't at all "anti - epi" but he's def been around for his share of "failed inductions". Anyway, my doctor happend to be in Europe as I went in 3 weeks early:( they should have sent me straight home.
With son #2 - my doc happened to be oncall so he told me to come in as my ctx were pretty strong and consistent. I ended up with a successful vbac. We did try the epidural at 7 cm but the stupid thing didn't work at all - next time I will definately go without. The insertion of that one was so traumatic for me - I was terrified so ask my why I did it??? I don't know. The pain would have been the sam e either way.
Obviously, I can't call anyone a coward - not everyone is able to just "squat in a field" and birth their babies. I have always admired moms who have the courage to give birth at home but I would have to agree withthe pp's that pain mgt needs to be discussed well before the actual birth.
I wanted a natural birth with my first. Instead, as labor wore on, we were goaded into first a paracervical (so midwife could rest) and later an epidural. They actually told me that my controlled sounding during my contractions was frightening other patients. :P Being the newbies that we were, we consented. We were repeatedly told by the nursing staff that I needed my rest, and the CNM needed a nap since she had been there so long. I think I saw her only a few times my entire labor. This did lead to a c/sec. Silly me actually chose an epidural for my 2nd. Didn't learn, did I? It got me an episiotomy, and internal fetal monitor and almost another trip to the OR. I did not choose it as soon as I walked in the door, however... and I had complications with it wearing off. That was enough for me to say no more. My 3rd baby was born with a half dose of fentanyl in late transition (what a waste of time!). My other 5 babies were born without medication of any kind... one more at the hospital and the rest at home. Only once did I fantasize about one during a homebirth... my son had a compound presentation and pushing was long, difficult and painful. I didn't know he was in this position until he was born. :P I am thankful this happened at home... who knows what complications it would have caused at the hospital.
Even when I opted for epidurals I certainly didn't want them immediately. When I taught childbirth education and worked as a doula, I taught my clients both sides of the epidural... pros and cons. I had one client opt for one out of many, and for her it made all the difference between feeling completely out of control and enjoying the birth of her baby.
I do have a friend from school, however, who once told me over the phone that she loved epidurals, because then she had the presence of mind to do her hair and makeup so the first pictures with baby looked nice. Sigh.
For those who demand epidurals as a way to feel nothing, I would just like to say that my epidural birth hurt a LOT more than my natural birth, and yeah, the damn think "worked" according to their theories as well. So, I exposed myself and my son to risk, to feel all the pain, and get to be stuck in bed with no food? No thanks, I'll keep it at home from now on. I seem to work better that way. :)
My experience with the epidural:
I was induced with baby #1, wanted to go natural, but could not bare being stuck in bed with back labor, so I "caved" at 4 cm and got the epi. It felt good for an hour or two...but then I could actually feel my butt and legs falling asleep, but I couldn't move them to help it go away. Weird. I was numb, but could feel parts of my body falling asleep. Then it was just uncomfortable. I could still feel some pain, and kept pushing the button to release more, bu it would just beep telling me thats all the relief I could get.
Then we went to the OR for FTP. They turned the epi up for the cesarean, but it took FORVER to get the right side of my belly numb. The anesthesiologist kep turning it up or whatever he was doing to try and get me numb adequately for surgery. When they finally had me ready, it was turned up so high I couldn't feel or move anything below my neck. Scary as hell. Couldn't feel myself breathing. I vowed I would have a homebirth next time around.
Well, fast forward. Child #2, had the homebirth. But, I remember thinking in labor that I would have gotten the epidural if I could have. I KNOW for a fact I would have gotten it. I was in so much freaking pain. If I was at the hospital for a VBAC--I would have gotten it. Crunchy Mama can call me a candy ass all she wants. Looking back, I am glad I didnt't go to the hospital for the epidural because we ended up with Shouder Dystocia. That would have probably been a NIGHTMARE.
Though I am glad I didn't get the epidural the second time aorund, and had my homebirth....I can't say if I get pregnant with #3, that I wouldn't be absolutely terrified of the pain of labor again.
After having been through a natural labor...I do not talk shit about any woman who wants an epidural. Yes, women back in the day went through labor withour one, yadd yadda, but now we have this pain numbing drug as an option nowadays--and when you are in the throes of labor, the idea of taking the pain away sounds pretty good. I have to say, if "back in the day" women were told about this new drug that takes away labor pain, I am not so sure there would have been half as many natuarl births. I think if a woman wants an epidural, let her have the epidural. She isn't a "candy ass", or a wimp or whatever you want to call it.
What does bother me though is when women are NOT being told ahead of time the risks of epidurals, and when they don't do their own research. Countless times in mommy forums women praise the epidural and, of course, never ever talk about the risks. And if you do, you are "scaring" the new moms.
I think that a big part of the emrging problem is in viewing the birth process in the medical model. As healthcare providers, we are taught that pain is uneccesary and should be managed effectively. We are taught that pain inhibits healing and should be pharmalogically managed in order to keep vital signs stable. And, we are taught that it is negligent, ethically and morally to let a patients pain escalate without intervention - in some cases it is consdered worthy of reprimand. But the birth process is different. It is self limiting, it is a healthful, normal body function, most times without the presence of disease processes. Until we begin to view birth as a unique and seperate entity from all other aspects guided by the classic medical model - the push for a more "civilized" and "dignified", AKA pain-free birth is what healthcare professionals will aim for as an ideal for women.
I have young girlfriends of mine who were like that... all they wanted was the epidural because they had heard so many horror stories about how painful birth was. I did lots of research before giving birth to my daughter and decided I would probably go with an epidural. I didn't feel the need to "prove" my womanhood by going all natural, but at the same time I didn't take the risks of epidural lightly. For me, it turned out wonderful.
I was induced at 41/1 (which I was not so happy about but at the same time I wanted my baby out) but my cervix had a lot of work to do (I was not dilated at all). They upped the pitocin q 30 min. At first it was great but a few hours later it seemed the pitocin kicked in at once and the pain/overstimulation was making me clench up my entire body. I was one of the early epidurals. Even though I was having ctx 2 minutes apart my cervix was only a 1, I think. But within an hour of getting the epidural I dilated to a 6, and then 2 hours later complete. So the epidural worked well for me.
I'm a last semester nursing student hoping to go into L&D so I will find it interesting to read responses to "how do you as a careprovider respond to this?" I'd like to know myself. All you can do is share what you know to be true and trust that woman has a genuine regard for her health and her baby's health.
www.sweet-motherhood.blogspot.com
Despite being educated on the pros and cons of epis and all things intervention, I ended up transferring to a hospital a little over 12 hours into my planned home birth, and having the whole gamut: epi, pit, efm, and eventually episiotomy. Basically, all the things I wrote that I DIDN'T want in my birth plan.
I planned for pain management, I read, I exercised, I prayed, I had support--and yet my labor went its own way. Posterior baby, contractions every minute and a half for that entire 12 hours. My midwife thought I was in transition when she first arrived because I was in so much pain and throwing up already, and yet I did not progress with all those hard contractions. I was only a 3 after all that time.
We transferred because of two things happening at once: my complete exhuastion, and some fluctuations in heart rate in my baby that my midwife wasn't happy about. All in all, I am happy to say that I did end up with a healthy baby. It was not the plan I wanted, but as things went their own way, I was still able to make informed choices. Call me a coward, but I don't think that I could have finished labor without an epidural. After two hours of pushing, I requested the episiotomy because I was exhausted and felt my pushes weakening with no progress to baby. I am pregnant now and hope for my ideal non-medicated, non-intervention home birth this time, but I do feel that at the time, I made the best decisions for us, and they were educated.
I agree with what one or more others have said--I think most women who get the epi and say they don't care, really just DON'T KNOW the downsides. I mean, why would a doctor offer it if ther are side effects? Honestly, that's what I thought before reading up on home birth. I assumed it was safe and without risks because so many women get them. And the women that do hear the risks I believe generally think that it won't happen to them, or that the risks are low, and feel that being out of pain outweighs those small margins. I think that would be great for women to be educated, and make informed choices, but I will never call someone a coward for the choices they make in birth, even if they're not the choices I would make. I think having to go through all that I did in my birth taught me that.
I didn't mean to neglect this thread. I've read every comment and they are all so interesting.
emjaybee asked something really intriguing. What if there were a completely and totally risk-free and side effect-free magic epidural? Would you get one in labor? I think most women would say, "Uhhh, yeah. Do you really have to ask?" But you know, I'm not sure that I would get one. I'm not sure that I wouldn't, either. Could something really be totally side effect-free if it disassociates you from normal pain? Does all pain need to be treated?
Personally, I have one very painful and fast labor (made worse by stress) and one not so painful and fast labor (except for transition. Ow.) My attitude toward pain and its purpose was in place long before I ever considered pregnancy. I was an athlete and was kind of used to the temporary pain idea. Just like pain has always given me an indicator of how not to move my body, pain in labor told me how to move my body. What if I hadn't have had that indicator? Would I have still known intuitively what to do?
I suppose it would really depend on the labor. emjaybee, you blew my mind.
Also, could someone invent this wonder-amazing-safe-happy-magic-painkiller soon please? A few weeks ago my back was totally out and I would have killed for one.
I chose a birth plan that involved my children coming into the world vaginally drug-free, so that meant no epidural (or any other meds).
Instead of being terrified of the contractions, I enjoyed them. I basked in the way they flowed through me and savoured every second of them. I talked to them, worked with them, I laughed as I felt them coming on and smiled as they peaked. I allowed my body to do what I was made to do.
I feel like it is because of the way I worked with my labour that they were both really short. I was six hours from my first contraction until I held my daughter, she weighed 7lbs 8oz. I was 2.5 hours from the time I had my water broke until I delivered my 9lbs 2oz son (myself) into the world. Some women say that I am "Lucky" since I had short labours, but I believe that it is because I didnt fight against it that my labours went the way they did. I also hate hearing women say "Well... my labour was REALLY painful" when they hear I didnt have any drugs, minimizing my labour. It wasnt comfortable at some points but it definately wasnt the worst pain I have ever gone through (which would be gallbladder attacks) and I would prefer to endure a bit of discomfort than choose to put my child in harms way.
I believe in women making informed decisions. I always encourage women to read and do research, to be fully aware of the actual risk they are choosing for themselves and their children, how it could effect the way their child enters the world, their success with breastfeeding, and the overall health of their child.
I forgot to add, if there was an option to make labour pain-free with no side effects etc. I would not choose to get one. Giving birth is like a drug to me, I love it. I enjoy it. It is the most relaxed I have ever been and I literally wouldnt trade the experience of giving birth (discomfort and all) for anything.