Tienchin Ho

Epidural Editorial

in my previous posts about epidurals, I wrote down the basic facts that most birth professionals agree on. Still, a pregnant woman reading about childbirth has figure out her own plan for dealing with labor pain. This decision depends on each woman's personal values. Values are not the same as facts. Values vary from person to person and from situation to situation. They are not objective truths the way facts are.

Here is one set of values:

• Why should I writhe in pain if an epidural can make it go away? Why not take advantage of modern medicine? A man wouldn't have his appendix taken out without anesthesia. A woman shouldn't be expected to endure pain unnecessarily either.
• I am a liberated modern woman who doesn't buy into the idea that a woman's place is to endure pain in exchange for the ability to bring forth life.
• I don't believe that the pain itself has any value. Just because women hundreds of years ago had babies without pain medications doesn't mean they would today.
• I have a choice.

And here's another set of values:

• Why should I use pain medications just because other people are uncomfortable with the noises I make and with me moving around?
• I am a liberated modern woman who doesn't buy into the idea that I have to compete in a man's world to feel worthy. I want to do this because it is not easy. I feel that doing difficult things, even those that are painful, adds value to my life.
• I don't believe that an epidural is safe enough. Just because modern technology developed the epidural doesn't mean I have to use it.
• I have a choice.

As a former laparoscopic bariatric (weight loss) surgeon, I do understand the first set of values. After all, I have seen modern technology do some really wonderful things for people. I am all for women's lib. I owe my career as a surgeon to amazing women who proved to the world that women have something special to offer the field of medicine. I definitely do not believe that women should be punished for having the ability to give birth. The spinal anesthesia I had for my cesarean with my first child worked great.

So why did I choose to have a birth without medications at home with my second child? Well, I understand the second set of values too. I like experiencing all of life. I even want to know the parts that are hard. I like knowing that my body labored and birthed my child. I like that it is an exclusively female ability. And I want to do it myself, without chemicals. Women's lib allows me to make a choice without feeling as if my individual decision may destroy the work of an entire movement.

I think the most important thing for anyone facing this decision is to be honest with yourself. Once you have enough factual information, let your own set of values guide you in what you feel is best for you and your family.

MYTH:
Parenting and childbirth are easy and painless if you could just "do it right."

TRUTH:
No matter what you decide, someone is going to judge you harshly for it and all of your future parenting decisions.

Epidural Side Effects

Informed Consent and Refusal

Watching someone in pain makes those around them want to help. What it means to be helpful depends on the point of view. Doulas and midwives have a tradition of methods for coping with pain that do not involve medications. On the other hand, obstetricians and most nurses are trained to treat pain with medications. Without any training in alternate pain control methods, it would certainly seem cruel to not offer medications.

Before any procedure or treatment, risks, benefits, and alternatives should be discussed. In the heat of labor, however, thoughtful discussions about the pros and cons often do not occur. For most families, learning about epidurals is best done ahead of time.

Mobility
In reality, many women with a “walking” epidural do not walk. A laboring woman may not wish to walk. Hospital safety policies and unintended weakness due to the epidural may prevent her from walking. As few as 20% and as many as 80% of women in studies actually walk with an epidural.

Having an epidural also prevents a woman from using warm water in a tub or shower as a labor aid. A woman with an epidural may need more help changing positions in bed, squatting, or trying to use a birth ball or bar. By dulling nonpainful sensations and discouraging positional changes, an epidural may allow the baby to come down the birth canal in a less than optimal position or keep a woman from knowing when to push.

Dystocia
Epidural anesthesia can slow a labor down. Most obstetricians agree that oxytocin should be used to augment the uterine contractions when this happens.

Hypotension
Epidural anesthesia can cause a laboring woman's blood pressure to drop about 10 - 30% of the time. Low blood pressure, hypotension, can threaten the blood flow and therefore oxygen flow to the baby. The treatment is to raise the blood pressure with intravenous fluids and medications.

Both a slower labor and low blood pressure can convince the birth team that continuing to labor is dangerous, leading to a cesarean section.

Other Side Effects
The narcotic in the epidural commonly causes itching that may be treated with further medications. Epidural-related fevers can also trigger an evaluation of both mother and baby with longer hospital stays. Epidural anesthesia is also associated with problems passing urine that can be relieved with placement of a bladder catheter. Finally, spinal headaches lasting days after the epidural is removed can be incapacitating.

Medications to treat unwanted side effects from epidurals are sometimes given preventatively before a side effect actually occurs. Since treatments of unwanted effects of epidurals are considered part of the original informed consent discussion, the treatments are usually just given without additional discussion with the family.

What is an Epidural?

Epidural Philosophies

Two philosophies exist regarding epidural analgesia during labor.

One approach is to use epidural analgesia as the preferred method of pain control almost to the exclusion of all other comfort measures. With this approach, mothers often intend to request an epidural early.

By controlling the pain, an epidural also offers an opportunity to preserve a mother’s dignity. Sometimes the prospect of losing control is more frightening than the pain itself.  Instead of risking her composure in the work of labor, a mother imagines enjoying the birth of her child in relative comfort. Some women experience this with an epidural. Some do not. Between 5% and 15% of epidurals placed for pain control during labor fail.

This approach avoids any difficult moments trying to explain less well-known methods to hospital staff. It has the added plus of being cutting edge by using modern medical technology to a laboring woman's advantage.

Another approach is to enlist the help of an epidural only after other methods of pain relief are not enough. With this approach, a laboring woman doesn't just grit her teeth and hope for the best. She prepares a variety of other labor coping modalities in advance. To do this she may need to invest in a skilled doula and an independent childbirth education class. In some cases, however, these methods are not enough. For example, labor pain may be associated with such anxiety that it interferes with labor progress. Or the pain so overwhelms a laboring woman that she is unable to cope with the work of labor. In these cases, an epidural can reduce anxiety or allow her to regather her strength. Sometimes painful procedures are needed during childbirth. An epidural allows her to be awake and alert during procedures such as a cesarean.

No matter which philosophy a woman subscribes to, epidurals come with side effects that can alter the course of labor. By using an epidural, a laboring woman gains some control over pain and over her own behavior in exchange for the loss of some control over her labor, her body, and her baby.

How Pain Signals Travel
During labor, pain signals travel up the spinal cord to the brain. Non-painful sensations about the cervix, uterus, and baby also travel up the spinal cord. The mother’s own expectations and endorphins adjust these signals. Based on all the information received, conscious and unconscious messages are sent back down to tell the body what to do. These nerves lie bundled together in the spinal cord surrounded by the spinal fluid. The spinal cord and spinal fluid are covered by a membrane called the dura.

Technical Details of Epidurals
Medications can be used to stop or change pain messages traveling in the spinal cord. With spinal anesthesia, these medications are placed inside the dura. With epidural anesthesia, these medications are placed outside the dura.

Using low levels of medications for epidural anesthesia lets the woman still have some sensation instead of being completely numb. These "walking” or “lite” epidurals are intended to allow the woman to continue to participate while having pain relief.

Combined spinal epidural anesthesia uses medications both inside and outside the dura. The anesthesiologist positions a special needle to inject a one-time dose of spinal anesthesia. Then a tiny flexible tube is placed through the needle to provide ongoing epidural anesthesia. The needle is removed, leaving the flexible tube in place. The tube is attached to a bag of medicine that may contain a narcotic like fentanyl or an anesthetic like bupivicaine or both. How fast and how much medicine goes into the tube can be set by either the hospital staff or the laboring woman. This is done by setting up a machine that gives preset doses with a push of a button. Combined spinal epidural anesthesia promises faster pain relief and less weakness than the traditional epidural by itself.