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"Patient Refusal" as Contraindication to Epidural Anesthesia?

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By Jill

There are few absolute contraindications to the use of epidural analgesia during labor. Contraindications to the use of a neuraxial (i.e., epidural or subarachnoid) technique include patient refusal, active maternal hemorrhage, septicemia, infection at or near the site of needle insertion and clinical signs of coagulopathy. (AAFP web site)

“Patient refusal” would definitely make the use of an epidural inadvisable, therefore making it a contraindication by one definition. I think this struck me as weird because I’m assuming, perhaps incorrectly, that “patient refusal” is not something frequently listed as a contraindication for treatments or procedures in any other area. 

Even if epidural anesthesia is viewed as a routine procedure and a cultural norm, is opting out of it really a contraindication?

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Reader Comments (10)

I am a nurse midwife and oddly, many hospital policies have things like "patient refusal" as contraindications. I don't know why but it is something I have seen quite a bit for things other than epidurals-- walking in labor, etc. Not usually for things like pitocin or induction, though. Go figure. I am guessing some weirdo just put that in at some point so everyone is copying it becuase it sounds "truthy".

December 9, 2010 | Unregistered CommenterCourtney

Woah! That speaks volumes.

December 9, 2010 | Unregistered CommenterC.Pratt

Well, if the patient does not want an epidural, she may be not likely to sit still for the procedure, thus potentially endangering herself (we are talking about needles in the spinal column, here!). But, actually, considering that epidurals are likely considered *elective* procedures, one might assume that all medically non-necessary procedures would be contraindicated by patient *not* electing to get one. As weird as that sounds.

December 9, 2010 | Unregistered CommenterKathy

Kathy, try this: If a patient does not want a total hip replacement, he could endanger himself if he refuses one. That was one of the procedures I googled trying to find similar wording about patient refusal. Maybe the epidural in this case is assumed to be a necessity and not elective?

Courtney, I'm glad you left this comment. Thanks for the perspective.

December 9, 2010 | Registered CommenterJill

So, contraindication to eating a Big Mac = consumer refusal? What a weird, unnecessary "duh" addition to that list.

The patient cooperation advantage actually bothers me more, because it implies that unmedicated women laboring in a physiologic manner are somehow an inconvenient burden to the staff.

December 10, 2010 | Unregistered CommenterKK

KK wrote: "it implies that unmedicated women laboring in a physiologic manner are somehow an inconvenient burden to the staff"

Yes. Rather than viewing pregnant/laboring women as opting in to elective procedures in the hospital, women are often viewed as difficult patients who are opting out. It's backward.

December 10, 2010 | Registered CommenterJill

A compliant patient is a good patient. We're supposed to be good girls and just go along with the recommendations of the powerful and wise doctors.

December 10, 2010 | Unregistered Commenternoturbettyhomemaker

Wow, how odd, and totally disturbing!

December 10, 2010 | Unregistered CommenterAlissa

As the daughter of a long-time L&D nurse, I can tell you that YES, patients with epidurals are viewed as being less of a burden to the staff. They're in bed, catheterized, on an IV drip, probably asleep, and constantly being monitored via those handy screens at the nurses' station. Unlike those crazy women who refuse an epidural, who are walking around, asking for something to drink or even (*gasp*) food, want to be off the monitors for more than 5 minutes at a time, and are generally crankier -- ya know, cause they're feeling their baby be born.

Of course not EVERY member of the hospital staff feels this way -- my mom is an exception -- but she's changed jobs twice in the last few years because of these pervasive attitudes and the bullying of the other nurses -- often much younger than her, who apparently view her as an inefficient old fuddy-dudd for actually wanting to talk to and interact with the patients.

December 10, 2010 | Unregistered CommenterRebecca M.

let's hear it for fuddy dudds.

December 11, 2010 | Unregistered CommenterSaanenMother
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