I come across quite a bit of information on the internet about how bad epidurals are, how risky they are, how they will eat your babies with butter and salt and torture puppies…Okay, maybe not the last two but I think you get my drift.
There is this idea of a “mandatory epidural” circulating on message boards on the internet and it seems to be really confusing and distressing for a lot of mom’s to be…and especially so for those that envisioned a straight forward birth with minimal intervention who suddenly find themselves categorized as “high risk.”
Have you noticed that I put “mandatory” in quotation marks? That’s because there is no such thing as a mandatory epidural. No procedure that can be done to you by a physician is mandatory. As an autonomous individual, you must consent before things are done to you. A procedure done without consent constitutes battery…unless it is an emergency situation and consent cannot be obtained. Then the standard falls back on what a mythical reasonable person (who is an aggregate of most reasonable people) would have consented to in a similar situation. This may or may not be what you, with your personal set of values, might have consented to had you been able to do so.
Maybe I can make it clear with an example. Lets say you were crossing the road in the morning on your way to the park with your dog and you were hit by a car. You roll into the ER unconscious and with no identification. Your right leg is completely smashed with significant vascular and bony injuries. You are receiving many units of blood but your heart rate and blood pressure are still unstable. The orthopedic and vascular surgeons make the determination that they cannot repair the damage and so they have to amputate your leg. They can do so without consent if the alternative is your death. Most reasonable people would agree with this course of action. But there are individuals who would not agree. There are individuals who have a personal value system under which they would rather be dead than lose a leg. But unless they have a tatoo that states so on their chest, or an advance directive in their pocket, they will have no legal grounds on which to claim battery via loss of leg.
While an epidural cannot be forced, there are situations where an epidural for birth would be strongly encouraged, i.e. you would receive a recommendation by an anesthesiologist that in their opinion, you should have one placed. Sometimes you might receive this recommendation from an OB. There are “anesthetic” reasons and “obstetrical” reasons for recommending an epidural to a patient…and usually both the anesthesiologist and the OB will be on the same page and make the same recommendation.
What are these situations? Well, “obstetrical” reasons for recommending an epidural usually come when the OB wants you to be in an OR for the second stage of labour (pushing) because there is a reasonable risk of sudden catastrophe requiring an immediate c-section or the need for good analgesia for obstetrical interventions like versions and the use of forceps. Common reasons for this may include vaginal breech delivery and vaginal delivery of twins. Sometimes, the OB wants an epidural to give the woman greater control during pushing…ie delaying pushing or gentle pushing in order to minimize the chance of harm to both the woman and the baby.
“Anesthetic” reasons for recommending an epidural generally have to do with maternal factors or illness. For example, epidurals are often recommended for class II and above obese women (BMI > 35). Very obese women face greater risks to their fetus from pre-eclampsia and gestational diabetes which both increase the risk that their fetus will not tolerate labour well. In addition they have an increase in the risk of C-section independent of these conditions which may be in part due to soft tissue dystocia (fat deposits impeded the fetus’ ability to move through the birth canal). For example, in one series 48% of women over 300 lbs required an emergency C-section. The other problems facing very obese women are due to concurrent cardiovascular and respiratory disease (hypertension, atherosclerosis/ coronary heart disease, obstructive sleep apnea etc), none of which get better with pregnancy.
Why recommend an epidural if less than half of these women will come to the OR? Seems like we’d do a lot of “unnecessary” epidurals, right?
It’s one thing to provide an anesthetic for a non-urgent “emergency” c-section…you know the kind where the OB books it and the patient comes to the OR an hour or two later. Provided the fetal heart rate is appropriately monitored and the fetus is doing okay, I would have the ability to position the obese woman optimally and really settle into the incredibly technical task of finding the spinal or epidural space through an abundance of excess adipose tissue. If I was unsuccessful, I would have the luxury of asking one of my colleagues for help (sometimes a fresh pair of eyes and hands does wonders) or I could revert to plan B, a general anesthetic.
But think about another scenario for a minute…think about the truly emergent “crash” c-section in an obese woman without an epidural. She’s run to the OR, the OB wants to pour a bottle of chlorohexidine on her belly and go NOW (never mind about the drapes or surgical instrument count) because the fetal heart rate is very bad or absent. Seconds mean baby neurons and also potentially the difference between a live birth and a dead baby. Now I’m faced with the choice between struggling to put a spinal in through all that excess adipose tissue or putting her to sleep and not being able to ventilate or intubate her. The risk of not being able to intubate a morbidly obese woman (not pregnant) after induction of general anesthesia is 7-13% (Buckley et al. Anaesthesia 1983; 38:840-51, and Lee et al, Anesthesiol Rev 1980; 7:33-6). This rate has been found to be as high as 33% in pregnant women over 300 lbs (Hood et. al. Anesthesiology 1993; 79:1210-8). Failure to intubate means possible maternal death or maternal hypoxic brain injury, aspiration and lung injury, damage to maternal teeth, tongue and pharyngeal tissues, an emergency cricothyrotomy which could damage any number of things in the neck…it also means fetal compromise, hypoxia and potentially death.
I’ve said I’d give my left breast for a pre-placed epidural in that situation…Sadly, the woman might have to give her baby because I cannot put her to sleep unless I am reasonably sure I can intubate her. That means sacrificing time in order to place a spinal or sacrificing time to numb her airway and intubate her awake (which is really like a bronchoscopy and not as bad as you might suppose). Why can’t I take a risk in order to save the baby? Well, the fetus doesn’t have personhood until he or she is a live birth…despite what you might individually think about that statement, the fetus is not my patient. The pregnant woman is my patient and to her I owe my primary duty of care. I cannot put her in danger to save her fetus. No matter how much she begs me. This doesn’t mean I would ever ignore fetal well-being…but if I have to choose, I have to choose the mother.
Most women that receive a recommendation for an epidural are happy to accept it…but conflict can develop when an epidural is recommended to a woman who really has her heart set on a
natural low-intervention delivery. Some women (a very very small minority, mind you) will shop around until they find someone who will tell them what they want to hear – that interventions are “unnecessary.”
If your OB recommends an epidural for birth I hope you have a long and serious chat with them about why they are making this recommendation. If you still have questions, I think a consultation with an anesthesiologist is in order. We used to be extremely gun shy when it came to performing general anesthetics in pregnant women, but maybe you don’t need an epidural to push out your baby in the OR. Maybe you are completely healthy and when you open your mouth and say “ahhhh” the tip of your epiglottis is visible…if that’s the case then it would be relatively easy to perform a general anesthetic with low risk in a pinch. The trade-off, of course, is that if an obstetrical intervention is necessary, you will not be awake for the birth of your child.
So what happens when the conflict becomes so severe that a woman insists we “do it her way?” Well, despite that economists and administrators like to refer to patients as “consumers of healthcare” it’s not really an industry where the customer is always right. Patients have autonomy, they do…but so do healthcare providers. As a patient, you cannot compel me to provide you with a level of medical care that I feel is unsafe, outside my usual scope of practice or at a lower standard of care than my usual practice. This does not mean I am practicing “defensive” medicine. It means that as a highly trained professional, I have the power to limit my practice to what I feel is safe and reasonable and in the best interest of the patient. This power is based in the ethical principles of beneficence and non-malificence as well as my professional autonomy.
I don’t have to “do it your way” just because you have patient autonomy. If the situation is elective, I can choose to do nothing or hand over to another anesthesiologist. If you show up with a true emergency I have to do the best I can with what I have at hand. Women who show up at the hospital with an obstetrical emergency end up with the least safe anesthetic environment available…a stressed provider working under incredible time pressure with a stressed team, likely incomplete health information and likely in the middle of the night with a double-whammy of fatigue and decreased hospital staffing levels. And that’s if they are willing to surrender themselves to us and let us do what we need to do without any demands and arguments.
Ironically, it’s the prospect of a woman in the middle that stresses me out the most – where things are sort of bad and it’s sort of urgent but my hands are tied due to lack of consent and we all have to sit around cajoling and counselling until a true emergency develops and we can just do the best we can under the circumstances. In that situation I will always wonder if I could have changed the outcome by choosing different words or using a different inflection or tone of voice…if there was anything I could have done differently that would have built enough therapeutic alliance with the patient to allow them to trust me and so decrease their risk.
The safety of any obstetrical anesthetic is a fluid thing that cannot be reduced to a recipe…It depends on the context which includes but is not limited to: patient characteristics (comorbid disease, airway anatomy, body habitus), anesthetic provider (amount of training and experience, level of fatigue) the clinical situation (time pressure due to fetal status, time pressure due to maternal status, time pressure from the OB, spinal/ epidural vs general anesthesia) and the OR environment (middle of the day vs middle of the night, how well the OR team functions). What I feel is safe during an elective slate in the daytime may not be the same as what I feel is safe during an emergency case at 2 am.
When an OB or an anesthesiologist recommends that you have an epidural for the birth of your child, that recommendation does not come from a cookie-cutter approach or a place generated by some desire of doctors to avoid liability. They are looking at all the factors surrounding your upcoming birth and trying to create a plan that will result in the least chance of morbidity and mortality possible for both you and your baby(ies). If you are told that the recommended epidural is required for an obstetrical intervention that, for example, is require 4% of the time, and that seems low enough to you that you’d like to forgo the epidural, ask yourself these questions:
If you were told that 1 in 25 people that walked into a room would be shot, would you walk into that room?
If you were told that 1 in 25 people that walked into a room would have their child shot, would you walk into that room?
I wouldn’t….but then I’ve seen what it looks like when someone’s been shot.