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.
theadequatemother 
Another excellent post. I can’t say enough how much I appreciate and enjoy your blog!
I love reading your perspective. Your blog is excellent for expectant mothers trying to sort out fact, fiction, mythology. Thank you.
I’ve had two children. For the first, I told my OB I’d like to labor without epidural. She was open, but firm in her response. I asked her the follow-up questions, and one was, “Isn’t it higher risk?” she quietly disabused me of that notion and explained that for me (known bilobed placenta with velantomous insertion) that, in fact, it was lower risk because we could be faced with an emergency situation and it’s far preferable to general anesthesia. I walked in planning to get one. However, I was at an 8 by the time I was checked, so she no longer recommended it. I had an easy, crazy intense labor but it gave me perspective. That’s not what I chose, so I get the luxury of being forgiving of womens’ choices. I still nearly ended in the OR that day.
Round 2, and I was induced b/c of my first (precipitous) labor. Again my OB gently advised an epidural. Again, day off, they pretty much talked me out of it.
Suffice it to say, I am really not a believer in birth plans. Everyone caring for pregnant women walks a crazy fine line between mother and baby. I’ve always appreciated the fact that they essentially have two lives to balance. Others (message boards, you say?) don’t seem so forgiving. It’s frustrating. I think this line sums it up, and I wish it was enough for everyone:
“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.”
Thank you again. Really enjoying your blog
Thank you for sharing your stories!
Always appreciate your perspective on these things.
Wow! Very well said. As an OB I appreciate how thorough and easy to understand your writing is on this topic.
Wow, this is a fascinating post. I’ve just found your blog and can’t wait to read more!
Thankyou for all your great writing about epidurals.
I am probably every OB’s worst nightmare, a homebirth midwife for 30 years, I have had 14 VBACs since my 5th cesarean and I weigh nearly 400 lbs. Obviously I’ve had no epidurals in my VBACs, but it is good to know finally why medical staff was so apoplectic about trying to force one on me. I’m satisfied with the choices I’ve made but I may make a different choice next time. Mercifully I have very fast very gentle uneventful vaginal births.
Very interesting! I had an epidural recommended for vaginal birth of twins. I had always planned to get the epidural at some point, so this was not an issue for me. They suggested it after 12hrs very slow labor, when they augmented with pit. Actually, what they did was put the line in, but did not run drug through it until I asked, when things started getting painful a little later. I did deliver in the OR, it was hospital policy, and I felt so much safer with the epidural, because if an emergency cropped up that demanded a C-section, I was ready to go.
Hmmm…I so regret my epidural. It didn’t work, and barely took the edge off the pitocin-amplified contractions. Then when I needed a c-section (no emergency), the anesthesiologist (a different one from the one who did the original epidural) could not piggyback the anesthesia because he could not get me numb on the left side. I ended up with general anesthesia.
Without the epidural, I could have been awake, had my husband with me, and seen my child. Instead I was terrified, had no one to comfort me, and woke up in the OR while someone I didn’t know was cleaning up. The nice anesthesiologist who tried to avoid general, my ob, my CNM, and the nurses who’d been with me during labor were all gone.
I’m sorry you had a bad experience.
When it really counts (ie we are counting on the epidural in the event of an emergency c/s in a high risk woman or high risk pregnancy), we don’t settle for less than perfect. I will resite epidural catheters and/or tinker with them until I see that they will provide good coverage.
Even in very difficult placements (like the morbidly obese women I used as an example) we can get epidural catheters working over 90% of the time…just maybe not on the first go.
Unfortunately, things don’t always work out the way we’d like them too and there are no guarantees.
Thank you. Anesthesiologist #1 was very pleased with himself, smiled like a big hero after he gave me the epidural. I’m sure it was hard to insert, as I’d been in labor for nearly 24 hours, and on pitocin for several hours and had depended on my ability to move around and bounce on an exercise ball to manage contractions. It was hard to stay still, and I was exhausted.
Anesthesiologist #2 was great and I could tell he did his best. Neither he nor the OB were happy about the general anesthesia.
Unfortunately, because I’m very overweight and nearing 40 and thus not a good candidate for VBAC, I won’t be having any more children. I can’t face another cesarean.
I have to kindly disagree through first hand experience that every care provider out there only recommends an epidural for true concern for their patient, instead of a fear of liability. I’d go as far to argue that the biggest motivation is to “cover their butts”, not so much of concern and true care for the patient. I believe ACOG even released a statement at one point admitting that rise in cesereans were because they do not get sued for doing csections too soon, but too late. Defensive medicine, straight from ACOG themselves. I was nothing more than a number to my OBGYN that delivered my first baby, and after the fact he as much as said he thinks every woman should have a csection. The fact that I wanted a vaginal birth was no concern of his – his convenience and wishes came before my own wishes for labor and birth. Family members overheard him talking to a nurse and he told her “Make sure she’s a csection.” I wish I were joking. And I wish I was the only person who’s ever had this experience with this doctor. I wish I was the only person who’s had this experience with any doctor, but it just isn’t the case.
No doctor is ever afraid of being sued because her patients came through safely. The fact is that every “oops, too late” c-section is defined by a severely injured or even dead baby. It’s the worst-case scenario, much worse than the possibility of doing a c-section too soon. When doctors worry about lawsuits, they’re worrying about dead and injured babies and mothers.
It sounds like your OB didn’t have much of a human touch. Don’t bame you for disliking him. But at the end of the day, when a doctor avoids the risk of lawsuit by being very cautious, she is first and primarily avoiding the risk of injury her patients.
I have to agree with you, Tessa. While it may not be the case with all OBs, there definitely situations where many OBs put their own needs about those of their patients. They are, after all, fallible human beings. I suspect that many doctors (and nurses, and anesthesiologists) may think they are doing what is best for the woman based on a faulty belief that the woman is incapable of tolerating labor pain. Sadly, many birth practitioners have only seen birth in a medical setting, which is much different than birth in an alternative birth center or at home.
Epidurals may be safe in and of themselves, but can lead to other interventions (such as augmentation) and eventually the woman’s birth experience is out the window. Women should absolutely have the right to choose whether or not they receive it. The very fact that someone suggest they be mandatory is abominable, because even though patients may be “consumers of health care,” they still have the basic right to refuse any treatment as long as they are fully informed of the risks. It might be annoying to have to sit and talk a woman into taking an epidural, but she is a human being receiving medical care, and it is part of your job to inform her. Maybe if more OBs were having the talk about the risks and benefits of epidurals and the situations where they are most beneficial before labor, fewer women would have so many questions during the chaos of labor.
I chose a home birth with my first child, and while I can appreciate why women want pain relief, and respect that choice, I don’t believe it is necessary for all women, and should certainly not be mandatory. To do so would be to further limit women’s freedom surrounding birth choices, leading to worse birth outcomes, higher rates of postpartum depression and more interventions. We need to seriously evaluate the state of maternity care in this country, for the sake of women and babies.
“I suspect that many doctors (and nurses, and anesthesiologists) may think they are doing what is best for the woman based on a faulty belief that the woman is incapable of tolerating labor pain.”
We (the docs, nurses and anesthesiologists) certainly know that women are capable of tolerating labour pain. We just think that if they chose not to, they shouldn’t have to. Anesthesiologists do epidurals on maternal request. ACOG supports a woman’s right to chose pain relief during labour. My own OB, even knowing I was an anesthesiologist, said to me that I might not need an epidural but one was available should I desire one.
In fact, my job on a daily basis teaches me just how good people are at tolerating pain. I’ve seen them tolerate the unrelenting gnawing pain of cancer. I’ve seen them tolerate baths to debride horrific burns. I’ve seen them tolerate awake tracheostomies for airway obstruction. I’ve seen them tolerate physical therapy after operations. I’ve seen more people tolerate more kinds of pain and more severe pain than any midwife or doula ever has. Trust me, anyone with medical education (the nurses and docs you point the finger at) knows people can tolerate pain. We know pain. We’ve seen pain. We fully support the right to not experience unwanted pain.
My post was not about the average woman giving birth. It was about special cases where risks are higher and where epidurals can lower risks and in these cases the OBs do talk to women long before labour about epidurals. Most of these women also come for an anesthetic consultation long before labour. This is important information that women should have at their disposal when making a decision about their care during childbirth. It is nothing but empowering to have accurate information about the risks you face. It is not empowering to stick your head in the sand, “trust birth” and hope that everything will be okay.
No health provider I have ever come across (myself included) has used the term “mandatory epidural.” I took that phrase from message board postings from women who have been counselled that an epidural would decrease their risks. If you read the post, you will see how much information I included about informed consent and battery in this context.
I never suggested it was “annoying to sit and talk a woman into taking an epidural” nor would I phrase it that way. We don’t talk anyone into anything, we simply provide information about risks and risk management.
In general, your comment provides more evidence of how little comprehension occurs when an individual come across information that triggers a highly charged emotional reaction.
I would like to point out that women already DO have the right to choose whether or not they get an epidural. I was given the choice with my first. It was suggested that I get one, because, well, the pain was not normal labour pain by any standards – long story, involving sepsis- but when I refused, the staff respected my decision. And in the end, I was begging for one, again, I CHOSE to have one. I’m not sure where the belief that women have no choice or are being forced to get epidurals is coming from. I know several women who had “natural” child births right in the hospital
Are you kidding me! Maybe we need to forbid very obese women from birthing we can save them from themselves! What are you doing for the 10% of the obese women that the epidural doesn’t work for. Are you placing a breathing tube, just in case they need that “EMERGENCY” crash section. We want to be prepared,”just in case”.
We should think be looking at why are there so many “emergency” c-sections?
If you were told that 1 in 4 women that walked into a room would have major abdominal surgery, would you walk into that room?
I think natural child birth is starting to catch on and women are not being pushed around by physicians that tend to “know better” any more and your job may be in danger.
“Maybe we need to forbid very obese women from birthing we can save them from themselves!”
NCB advocates really have to figure out what they want. Do you or don’t you want to be addressed as an adult? Do you or don’t you want to be told honest information about health risks? Or would you rather everyone pretend that your health problems aren’t risky so as not to hurt your feelings?
Which is it?
If I had to get through one of two rooms to get my child, one of which had a 1 in 4 chance of a fairly straightforward, common surgery, and the other of which carried a 1 in 100 chance that my child would be smothered to death, absolutely I would walk into the surgery room.
As a matter of fact, I would do it even if there were a guarantee of surgery in the first room. I have a scheduled ERCS coming up this summer and I couldn’t be happier.
The way you have described how you practise here does seem defensive. You’ve gone to some lengths to describe the things you want to do “just in case a CS is needed” and why you want to do them (which is very much appreciated) but not gone into any detail about the things that can be done to minimise risk of the CS itself. I’m not surprised by that or anything…. It seems a fairly typical OB approach….?
In one breath you say “You have a choice. No one can do something to you without your consent.” In the next you basically say “My way or the highway.” Most women would “consent” to pretty much anything if the alternative is being abandoned and possibly being left without any care at all.
I don’t know, while the information here is very much appreciated, this post seems quite disdainful. Of obese women, of women who have tried to inform themselves, of women want a “natural” (ha!) birth…. I wonder if there is there any woman you are not contemptuous of… The slim and obedient ones with no internet access I am guessing….!
I have to agree with this poster- the tone of this blog is contemptuous.
“the tone of this blog is contemptuous”
Contemptuous of what? The fact that NCB advocates spread misinformation and lies? The fact that the surest sign that someone is ignorant of science, statistics and obstetrics is that they claim to be “educated” about childbirth?
As far as I can tell, she was quite restrained, but were she contemptuous, who could blame her? The mistruths, half truths and outright lies about epidurals that are circulated by NCB advocates are worthy of contempt.
With regard to: “Most women would ‘consent’ to pretty much anything if the alternative is being abandoned and possibly being left without any care at all.”
No care provider can abandon a woman in labour. If a woman in labour did not want to accept our recommendations, we would continue to care for her to the best of our abilities. We would not abandon her and we would manage risk as much as possible without committing battery.
Battery, in this case, is performing a medical procedure on a patient without consent.
In contrast, because a care provider cannot be compelled by an individual to provide care that they feel is unsafe or not up to their usual standard, in a non-emergency situation, they have the right to refer a patient elsewhere if that patient is requesting a course of action that, in the judegment of the care provider is unsafe.
While ofcourse there are times women may truly need an epidural, it’s extremely rare, then compare that to the 90% rate of epidurals in some hospitals and it seems the argument for epidurals has been pushed far too far. Add to that the fact that on average studies show just 30% of OB’s recommendations are actually based on fact, and you have yourself a dilemma as a birthing mother. Do you trust an OB to truly be making the right decision for you? I can tell you many women don’t. Epidurals are renown for causing complications. They add huge risk to the birth, and you have to weigh up that risk against the risk of the patient. If a woman is able to at least trial labour, then an epidural can wait. Giving her the epidural ‘just in case’ could be the very thing causing an emergency later on.
Keep in mind that epidurals are usually given on the woman’s request. Most women feel that pain relief in labour is very important, and make an educated choice to accept the risks which come with that pain relief.
Yes, but the ultimate goal of the people who’ve showed up to attack TAM is not that women get what they want, but to make sure women give birth in the way they see fit. Nevermind that the vast majority of women want safe and effective pain relief during birth.
The first they referring to birthing women and the second they referring to the natural birth advocates. Sorry, my ability to communicate clearly seems to be lacking today…
I hold out a dim hope that some of the people who claim to be advocates of women’s choices in birth actually do believe that, somewhere deep down in their souls.
Please feel free to prove me right, natural-childbirth-types . . .
Please offer us proof that “epidurals are renown [sic] for causing complications.” Other than sometimes causing a drop in the mother’s blood pressure or causing a spinal headache, what demonstrable harm does an epidural do? Studies have demonstrated that they do not cause the “cascade of interventions” (meaning they don’t lead to c-section), nor do they “drug” the baby. I hear these garbage arguments trotted out all of the time, yet NO ONE in the NCB community can offer substantive proof that they are true.
And why is a 90% epidural rate a problem anyway? I had my first child unmedicated because I actually bought into this natural birth crap and it was sheer misery. Why should we actively encourage women to suffer? It’s paternalistic and misogynistic.
“there are times women may truly need an epidural, it’s extremely rare”
Actually, 100% of women who request an epidural need it. It is pain relief.
Or are you prepared to argue that no one needs pain relief for severe pain?
I find it really offensive that you say that epidurals are rarely needed. One’s level of pain is subjective so how could you really know? It seems you are following along with the classic NCB rhetoric that seeking pain relief during childbirth is selfish and unnecessary. Is this what you are saying? I would imagine that an epi rate of 90% means that women are seeking out pain relief, what gives you or anyone the right to judge that? I am a member of many natural childbirth groups and have seen so many women ripped apart for choosing to labor comfortably. It seems that diehard NCB advocates are determined to make every woman give birth in a way that they deem worthy, and I find that attitude repugnant. Enough already. No more ripping mothers apart for having C/S and epidurals,let us birth the way we want.
To naturalmamanz,
I would be interested to see where your reference for the statement that ‘30% of OB’s recommendations are based on fact’ is from. This would seem to imply that it comes from a study where OB’s admitted to using false information 70% of the time. This seems an unlikely study.
I have worked in several countries and it is a common trend across these that the care provided for patients is based on as much evidence based practice as possible. There are of course times when medicine is an art and not a science but when it comes to having a baby its a high stakes, low odds game and practitionners provide information based upon their training and judgement and the aim is always a healthy happy baby and mother. Although the birth experience is life defining it should not be at the cost of you or your baby’s life.
Doctors are required to undertake ongoing professional development, our cases and critical incidents are reviewed and discussed and much time is spent on trying to identify possible risks and minimising them.
The original post was in reference to women in high risk pregnancies due to their high BMI. The cumulative risks faced by these women are a matter of fact, the statistics of which are well within the public domain,
The risk of failed intubation is up to 33%, thats 3 in 100. In some women this will lead to delays which will damage or kill their baby, another group may inhale their stomach contents which at best will cause pneumonia at worst could kill them and then another portion will be brain damaged or die from a lack of oxygen to their brain.
These events are devastating to everyone involved, their death will affect the lives of their parents, partner and children forever. Every member of staff and the community as a whole will grieve.
Misinformation of the sort that is sold as fact to expecting mothers, such as the claims of the ‘studies’ you cited, causes distrust between women and their healthcare providers and disempowers them from making informed decisions about their healthcare WITH the professionals caring for them. It does not support women in making choices and the people spreading this never seem to hold themselves accountable for when it goes wrong.
When I read your blog; my very first thought was: “I hope no one reads her blog. She has given all the power to docs and medical staff and has made them (as per usual) the all great and powerful Wizard of Oz. I love how she crossed out NATURAL childbirth and put “low intervention delivery”. <<<—– EVERYTHING that is wrong with the way Childbirth is handled today. It's all about "fear" and "what if". You can not have faith and fear simultaneously. The medical world lives in FEAR (of being sued) and has given up all faith in the amazing, miraculous, human body's ability to birth! The truth is sometimes things do go horribly wrong and thank God for advancements in medicine when they do…. but things don't go wrong as often as the medical community would like to terrorize every woman into believing….. Just because something CAN go wrong does not mean it will go wrong…
Why is “faith” better than being prepared? Do you apply that to every area of your life?
Things don’t always go wrong. But there’s no way to know in advance how things will unfold, and since we have decided that every baby and every woman deserve to live through childbirth (an incredibly new idea for humanity), that means doctors have to be cautious in every single case.
Often the caution turns out to be unwarranted, and sometimes we can look back and know that a given intervention wasn’t actually necessary in this case. But that’s much better than looking back and saying, if only we had intervened when we weren’t sure if we needed to, this baby or this mother would still be alive.
Great post. I’m a former telemetry nurse, and you’d better believe we wanted everyone to have a saline lock in case their heart started doing something funky and they needed IV meds fast. So I can definitely appreciate your point.
As a L&B nurse and future midwife, I appreciate your opinion and understand it. However, I have some issues….in my experience (9 years, various hospitals) the epidural most commonly used is the ‘walking’ epidural. This is the same when a patient has been asked to have an epidural – ie for twins. (not for vaginal breech as it is more important that the mother be able to move and push than be comfortable if piper forceps are used). In the case of the twin birth, or some other scenario in which you can reasonably anticipate the need for emergent intervention, the epidural is not routinely “topped up” to a c-section dose. This would only happen if the emergency occurred. But, generally speaking, the emergencies that occur can not wait 10-15 minutes for that top-up to take effect. So a GA is performed anyway. And as well, in my experience, many of the complications that have occurred might have very likely been avoided if the woman had freedom of movement and was able to be upright, not supine in lithotomy position, to push her twins out. Also, instead of practitioner panicking over the 2nd twin who is tranverse leading them to perform a breech extraction and oops now membranes have ruptured and theres a cord prolapse so stat section = GA – when all the while the FHR was stable before they starting fiddling- why couldn’t we wait? With mother having sensation and ability to be upright using gravity, likely the second twin’s heaviest part (head) will fall into the pelvis. Anyway, I could go on…. Just my thoughts. And most women are not 300lbs….care needs to be individualized.
Heather, you ask some very good questions.
What the anesthesiologist chooses to put into an epidural doesn’t follow a recipe-like approach but is based on the clinical situation and the wishes of the patient.
For example, pushing in the OR with an epidural could occur with an unloaded epidural, a lightly loaded epidural or a heavier block. If my patient had a difficult airway (the example I used in the post) we would proceed under the assumption that a GA isn’t going to happen quickly and would likely have some kind of block established. A woman with an easy airway may not need to have any block at all.
Sometimes a GA is used in a woman who is at low risk for complications under GA because it seems faster than topping up the epidural. Sometimes a GA is used for other reasons – for example, with fetal head entrapment during a vaginal breech delivery, the anesthetic gases used during a GA will relax the uterus and may allow birth without a C/S.
These are only a few examples, the approach to any clinical situation is incredibly nuanced.
For women who are deemed to be at high risk for a C/S but have some comorbidites that would make GA risky who are labouring in a birthing room, an epidural can be topped up as soon as the C/S is called, en route to the OR. As it takes about 10 minutes to move a patient to the OR, get them on the OR table and prep and drape, there is ample time for a surgical block to be established.
As for your assertions about leaving well enough alone and allowing different positions for pushing in women with multiples, that is entirely outside of my area of expertise so I cannot offer any meaningful comments.
World Health Organization’s stated maximum medically necessary c-section rate for any given country: 10-15%. The United States c-section rate: well over 30% and climbing. The push for intervention during the birthing process in the United States is abundant and strong. While I do understand some of your commentary about obesity in our country and the health challenges that proposes (maybe our medical system should focus more on wellness lifestyle “intervention” instead of prescription pad proficiency), the fact of the matter is interventions are grossly overused during the birth process. Many other developed nations still have midwives primarily overseeing the birthing process with much better birth outcomes and fetal and maternal mortality rates. Crossing out “natural” and replacing with “low-intervention” is an interesting move. As if saying “natural” birth doesn’t really exist. My wife has had two “no-intervention” (literally) births so far, so I guess they do.
“World Health Organization’s stated maximum medically necessary c-section rate for any given country: 10-15%.”
The WHO withdrew that recommendation back in 2009 acknowledging that there had never been any data to support it.
So did they replace it with some numbers that have the data to back it up? Do you think that, in general, 25%+ of low-risk women need to have a c-section?
“So did they replace it with some numbers that have the data to back it up?”
No, they didn’t suggest new numbers because there is no scientific evidence for claiming an “optimal” number of C-section. According to research done by none other than Marsden Wagner himself, the average C-section rate in countries with low rates of neonatal and maternal mortality is 22%. Low rates of neonatal and maternal mortality are compatible with rates in the mid-30’s.
Low rates of maternal mortality? Really? So then why is maternal mortality on the rise again in North America? You can’t just blame the unhealthy women of the world, they are still in the minority!
“So then why is maternal mortality on the rise again in North America?”
It’s not. The US has twice expanded the category of maternal death to include many more conditions, and a much longer time period (up to a year after birth) than many other countries. Almost all the purported “increase” in maternal mortality can be shown to have occurred within one year of each of these two changes.
So moms and babies have always just died of complications of childbirth, at about the same rates, despite what we do. So all the interventions and c-sections have done what for us?
“So moms and babies have always just died of complications of childbirth, at about the same rates, despite what we do.”
No, modern obstetrics has lowered the neonatal mortality rate 90% and the maternal mortality rate 99% in the past 100 years. Childbirth is inherently dangerous but most NCB advocates don’t realize it because obstetricians have made it so safe.
I wasn’t comparing the early 1900’s to today. More like the 1980’s to today.
“More like the 1980′s to today.”
I’ve already explain that almost all of the purported “increase” in maternal mortality is due to expanding the definition of maternal mortality in the US.
Moreover, if you look at the reasons why women die of pregnancy related complications, most women who ultimately died could have benefited from MORE interventions not less. One of the leading causes of maternal mortality is now heart disease (both congenital and peripartum cardiomyopathies).
Really? No pulse oximetry. No capnography. No 2D ultrasound. Breech vaginal deliveries and high forceps still in use. Epidurals high dose and dense (forget about that birthing ball!). No triple-screen– have to get that amnio if you’re worried about trisomies or NTD!
So wait, are you acknowledging that prominent and well-respected medical authorities sometimes put out recommendations and information that is not “science-based” or based on fact or the best available evidence? : ) Look, the WHO is still a political body that can be influenced politically. I get that. But the logic/reasoning and evidence for maintaining a much lower c-section rate than 30-35% makes complete sense. Look at all the countries in the world who have c-section rates in the 10-15% range and yet have maternal and infant outcomes equal to (or often better than) the United States. Its not rocket science here.
“Look, the WHO is still a political body that can be influenced politically. I get that.”
No, I’m not sure you do.
Who is responsible for the “optimal” rate of 10-15% that never had any scientific evidence to back it up. None other than Marsden Wagner during his tenure at the WHO.
“Look at all the countries in the world who have c-section rates in the 10-15% range and yet have maternal and infant outcomes equal to (or often better than) the United States.”
Evidently you have no idea that there are only 2 countries that meet those criteria (Kuwait and Croatia) neither of which is known for its comprehensive health statistics.
Goody for your wife, Adam. Until men start giving birth, I don’t want to hear any of you weighing in on how I should give birth.
Do you understand that the whole point of an intervention is to take action BEFORE something goes wrong? That’s what kills me about this “overuse of intervention” crap. The very point of them is to prevent bad outcomes. Do you think that women in the developing world are enjoying their “intervention-free” births and the accompany maternal and perinatal mortality rates? Wake up!
“Do you understand that the whole point of an intervention is to take action BEFORE something goes wrong?”
False. Taking action for the PREvention of something is called prevention, not intervention.
“Goody for your wife, Adam.”
Yes it was! I am so incredibly proud of her!
“Do you think that women in the developing world are enjoying their “intervention-free” births and the accompany maternal and perinatal mortality rates? Wake up!”
Look at the data before commenting on it. Countries with much lower intervention rates than us have better maternal and infant mortality rates than us. For example, Holland has a home birth rate around 80% or so attended almost entirely by midwives, and their outcomes are better. : )
“For example, Holland has a home birth rate around 80% or so attended almost entirely by midwives, and their outcomes are better. : )”
Boy, you really have fallen for the NCB claptrap hook, line and sinker.
The Netherlands has a homebirth rate of 27% and falling, their perinatal mortality rate is one of the worst in W. Europe and the perinatal mortality rate of Dutch midwives caring for low risk women (home or hospital) is higher than that of Dutch obstetricians caring for high risk women.
The Netherlands, contrary to the lies of homebirth advocates, is actually an object lesson in the dangers of midwifery care.
Is Holland a developing country, Adam? HINT: “developing world” is another term for the Third World. Does that make it any clearer? Why don’t you look up the maternal and perinatal mortality rates in Afghanistan or Uganda?
Adam, you need to study some obstetric history and some semantics. Before modern obstetrics, midwives and doctors would still perform interventions – after the baby was known to be trapped or already dead. They would intervene after events took a turn for the worse, and would sometimes be able to salvage a mothers life or the baby’s life.
Today, we can intervene in the course of events to prevent tragedy. Yay for us!
Skilled medical practitioners recommend INTERventions based on existing risk factors and/or emerging conditions, for the purpose of PREvention of mortality and severe morbidity. Sheesh.
I have rarely – if ever -seen an artificial rupture of membranes, epidural, every 2 hour vaginal exam, or an oxytocin augmentation be life-saving. Certainly the women in developing coutnries are not missing out due to lack of access to these interventions (which is what we complain about). From my experiences in Africa, it is the life-saving interventions they are missing, and that’s not what we’re talking about here. In fact, because of our glorious western/northern/whatever influence, artificial rupture of membranes and synthetic oxytocin are being unsafely used to the detriment of both mothers and babies. Yay for us!
“I have rarely – if ever -seen an artificial rupture of membranes, epidural, every 2 hour vaginal exam, or an oxytocin augmentation be life-saving.”
Really? And how many thousands of deliveries have you attended?
As an OB nurse for 9 years….a couple….
Then you should know better. Pitocin augmentation, induction, and C-sections save literally tens of thousands of lives each and every year.
It’s sad that you actually believe that. But not surprising.
“It’s sad that you actually believe that.”
It’s pathetic that you do not know that, but not really surprising.
Childbirth is inherently dangerous. Just ask any woman in a country that doesn’t practice modern obstetrics with its full panoply of interventions.
There is no scientific basis to NCB. It was created by Grantly Dick-Read, a racist, sexist eugenicist, in order to convince white women of the “better” classes to have more children than “primitive” women of the “lower” classes.
NCB is a cult based on ignorance. There is no scientific evidence that unmedicated childbirth is better, safer, healthier or superior in any way, no matter how much NCB advocates try to pretend otherwise.
I didn’t say that childbirth wasn’t “dangerous” and if you actually read what I wrote, you’ll notice that I didn’t even refer to c-section. Of course c-sections save lives, that’s what they were invented for!! It’s sad that they are just plain and simply overused now due to lack of patience. Augmentation of labour does not save lives, it saves the practitioner some time. When there is a fetal life to be saved, what would pitocin do exactly? When there is a true obstruction, or some sign of fetal distress, all that pitocin does is cause more fetal distress. Which it will also do when it’s used unnecessarily as it is MOST of time …before even a dystocia can be diagnosed. “Slow” does not equal “dystocia”. AROMs are still used routinely to “speed things up” instead of for augmenting in “dystocia”. I haven’t seen and AROM be lifesaving. If you have, please explain. I mean maybe an AROM can help with 2nd stage fetal distress if your client is a multip and you want her to push the baby out now, but that’s really all I can think of…..but it’s routine use? absolutely not gonna save any lives (just potentially cause prolapsed cord, chorio, or dystocia d/t asynclitism etc).
If I only went by what I’ve seen, I’d assume there was no such thing as malignant hyperthermia, transfusion reactions, aspiration pneumonia, or coronary vasospasm with unopposed beta blockade in the setting of cocaine intoxication. If you want to be a real medical professional, you read the studies to find out what works– not just the ones that say what you want to hear (i.e., all OB interventions are overused, it’s all CYA medicine, OBs don’t care about patients etc).
Augmentation of labor gives women a chance to have a vaginal birth that they may not have otherwise had. But, then, I’m not an L&D nurse so I wouldn’t know.
This is a response to Heather, wondering how augmentation benefits women and babies during labor. I am only one person, therefore this is an anecdote, but in my case, it absolutely prevented a Csection. After 12 hours of rambling labor (post SROM), I had a choice–pit augmentation or Csection. I agreed to the Pit and my children were born some hours later, vaginally. If I had lived in some place where pit (and Csections) were unavailable, it is entirely possible that my babies and/or I would have died…possibly from infection or fetal intolerance or hemorrhage. I did hemorrhage and I got MORE pit for that so I didn’t bleed to death.
“This is a response to Heather, wondering how augmentation benefits women and babies during labor.”
I never asked this question actually, I wasn’t wondering anything, in fact. I made a statement…that augmentation doesn’t save lives. It didn’t save your life either. Likely you would have laboured without it if you were allowed the time to do so. But in fact you were given an unnecessary ultimatum. Augmentation saved you from a c-section only because you were birthing in an impatient and distrusting medical system. It did not ‘save your life’.
“Crossing out “natural” and replacing with “low-intervention” is an interesting move.”
Yes, it is. “Natural” has come to have a value-judgement attached to it. Low-intervention is simply a statement of fact.
Did your wife engage a midwife or other birth attendant? That’s an intervention. Did your wife have you in the room offering support? That’s an intervention. Any listening to the fetal heart with a hand-held doppler? Perineal massage? Control of the head during crowning? All interventions.
Did you go to a prenatal class? Use hypnobirthing, music, massage, or warm water for comfort during labour? Use a birthing ball? A squat bar? All interventions.
I’ve been a “high risk” for 5 of my 6 full-term pregnancies, mostly because I’m in the over 35 BMI range (which, by the way, is not “very” obese, but just obese), but also because of a uterine tear and 2 VBACs. The only anesthesia I’ve had was for my C-section (baby #4). I understand that, from a medical-intervention-is-best perspective, an epidural might seem like a good choice for some women. But for me, the freedom of feeling every minute of labor was far more empowering than the freedom from pain that an epidural offers. In fact, the effects of the spinal that was required for my C prevented me from bonding with my daughter for over 24 hours, while the pain of natural childbirth was over as soon my sons were placed on my chest.
That’s very different from my experience. Can you explain how the spinal interfered with bonding?
You are right about “very obese” that was sloppy writing. I have edited the post to read “class II obesity and above” which is much more precise.
Do you understand that the whole point of an intervention is to take action BEFORE something goes wrong?
If we live by that moto we would NEED to live in a bubble and NEVER reproduce because things often go wrong in life as well as child birth.
The fact that the surest sign that someone is ignorant of science, statistics and obstetrics is that they claim to be “educated” about childbirth?
http://www.medscape.com/viewarticle/573875_3
http://www.medscape.com/viewarticle/449424
But, generally speaking, the emergencies that occur can not wait 10-15 minutes for that top-up to take effect. So a GA is performed anyway.
You are so RIGHT!!!!
http://www.medscape.com/viewarticle/752316_4
Direct quote from the article you referenced:
“The recent ‘Saving Mothers Lives’ report emphasizes the importance of fast speed of block onset after an epidural top-up in certain situations.[30] One of the deaths directly due to anaesthesia resulted from inability to ventilate the lungs during general anaesthesia for a Category 1 Caesarean section. This woman had a functioning epidural catheter which the anaesthetist elected not to top-up because of the perceived delay before achieving surgical readiness. In all the trials included in this meta-analysis, solutions containing lidocaine and epinephrine, with or without fentanyl, showed median onset times <15 min. Using this solution to top-up an epidural catheter in the delivery room, that location being recommended in the report providing an anaesthetist and suitable equipment is available, creates the opportunity for surgical readiness comparable with administering general anaesthesia, which has a higher risk of serious complications."
See Bjornestad et al (Acta Anesthesiol Scand 2006; 50:358-63). Median time to surgical block using lido or chloroprocaine: 5-8 minutes. There is not much difference between that and the time required to ask the mom’s support person to leave the room, preoxygenate the mom, induce a GA, intubate and secure the airway and start maintenance anesthesia…that also takes about 5 minutes.
EXACTLY!!! Even with the epidural in place the mom still DIED!!!! So how can you say that having an epidural cath in place is safer???
The epidural didn’t lead to her death. Failure to use the epidural directly led to her death.
This epidural would have been lifesaving.
Dona, this entire subject is a bit personal for me because I had life-threatening complications after the birth of my first child. I had a cervical laceration, and began hemorhaging as soon as the placenta was delivered. Because I had delivered unmedicated (without even a heplock), I endured manual examination of my uterus and the manual extraction of several large clots without the benefit of pain medication. This was far more painful than the birth of my child, with the added bonus of realizing that I might actually be bleeding to death. Fortunately, I passed out from pain and blood loss just before they ran the I.V. and gave me some magnificent drugs just before wheeling me to the O.R. Even with prompt care (my husband estimates it was no more than 15 minutes from onset of the crisis to being taken to the O.R.), I narrowly missed getting a blood transfusion.
No shit things go wrong in life as well as childbirth. Does that mean that I want to live in a bubble? Of course not! But I will take adequate precautions, like wearing a seatbelt when driving, a helmet when riding a bike, and having a heplock during my next delivery. If having an epidural sited (not necessarily turned on) is safer in some instances, yes, I would agree to it.
Cheers to you and your wife, Adam. I’ve had births attended (watched and checked with handheld doppler by a dr) and unattended. I didn’t realize I was a ncb ‘advocate’ by not desiring pain medication for my 3 labors. I know this, the desire for pain medication can itself be an intervention in itself that can affect the labor and delivery. My providers would’ve transfered me to our decided upon in advance hospital if I desired pain medications. A good provider is aware of and shares with you ALL your options, even those options they cannot provide.
Provided I’m speaking just to the routine use of drugs in labor. Dulling the pain with drugs interferes with the chemical processes inherent to the reproductive process that is birth, desiring drugs is a powerful process and worthy to keep in mind as we re-re-redefine natural childbirth. That is what my drs told me, but I don’t need a dr to know that drugs dope me up and my kid if that is what I chose.
When I hear the phrase “dope me up” I think of level of consciousness being affected; did you mean something different? I have had two spinals (for cesareans) and an epidural (for a VBAC), and although they provided excellent anesthesia in the desired region, my mind wasn’t affected at all. Unless you count the nap I was finally able to take after the epidural, which I credit with giving me the strength to push when the time came!
Hi! Thanks so much for this post. I’m a Canadian studying public health in the US, focusing on women’s reproductive and perinatal health, especially childbirth practices. I was suprised about one of the ‘ob reasons for use of epidural’ and am genuinely interested in knowing more/reading up on literature, etc. concerning this:
“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.”
I guess my lay perspective was that ‘feeling’ would be more protective than ‘not feeling’ (I know that is much too general) during pushing. I can only imagine how busy you are, but I would love to know more about this and maybe correspond by email? I can be reached at sburke (at) jhsph (dot) edu
Thank you!
Sarah – when you don’t have an epidural, the urge to push can be overwhelming, and it can be incredibly difficult to control your pushes. I delivered a 6 lb., 4 oz. baby without pain medication, resulting in a second degree tear and a cervical laceration. The strategy for my next delivery is to have an epidural, for both pain relief and to minimize the chances of reopening the scar on my cervix.
Hi Sarah,
You might be imagining that the only harm during pushing would be perineal tearing (and epidurals, to be clear have neither been shown to decrease or increase tearing)…it’s actually a lot more interesting than that. I’m going to give you some examples, but this is not an exhaustive list. Most of these scenarios are sufficiently rare that evidence is restricted to case reports or case series only becuase it would be pretty impossible (and probably unethical) to do an RCT…in other cases the situation is common but it would still be unethical to do an RCT.
Some woman cannot safely push because they will not tolerate the associated hemodynamic changes or because pushing puts them at unnecessary risk. For example, women with (stable) arterial dissections, mitral stenosis, some congenital heart defects (pre and post repair), unsecured cerebral aneurysms or arteriovenous malformations. Paraplegic women who have autonomic dysreflexia are at risk for an attack with pushing or even with descent into the birth canal during the second stage. All these women may benefit from epidural analgesia for vaginal birth.
Sometimes the epidural is used to blunt or eliminate sensations that lead to an overwhelming desire to push when this might be hazardous to the baby (prems, breech, twins)…or the mom (the example of a prior cervical laceration is a good one).
You can read more about all this in any OB textbook or OB Anesthesia textbook to get you started and then branch out from there into peer-reviewed literature.
My doctor is asking me to have an epidural for my VBAC. After reading this, I understand her much better and I agree. Thank you. I am very grateful for your perspective. It’s exactly what I needed to make the right decision.
Thank you for explaining this so well. I wish I had known this all, and understood it, much earlier. The idea that birth should be natural and intervention-free harms many women, who feel powerless to do anything but try and deal with overwhelming pain. Understanding the hows and whys of interventions gives me the power to make informed choices. I am grateful.
[…] The one benefit of an epidural catheter is that it can be topped up for c-section leading to a route to safely establish surgical anesthesia in women at high risk for serious complications of general anesthesia. For more information and an example, you can read my post “the mandatory labour epidural.” […]
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