A perfectly reasonable request.

The last time I was on call I went walking through the maternity unit/ LDR.  I do this every time I’m on call, not because I’m “trolling for work” or trying to find an impressionable woman in labour that I can foist an epidural on, nope it’s part of “resource management.”  See, in the middle of the night, I am a scarce resource.  I am in charge of covering the main ORs, the labour and delivery unit and their ORs, the patients in the post-anesthesia care unit, the patients on the acute/ post-operative pain service (those with epidurals, on patient-controlled analgesia or PCA and those with peripheral nerve blocks).  Oh, and I’m airway back-up for the emergency department and the intensive care unit.  On a busy night, a lone anesthesiologist can feel quite thinly stretched, and that, coming from someone who is pretty inflexible (physically, hopefully not mentally) is fairly uncomfortable.  I have some back-up in the form of the “second on call” but that person is comfortably snoozing at home and generally 20 minutes or more away.  I saunter through LDR to see what’s what so that I can figure out how to prioritize emergency surgical cases.  Is there a woman about to attempt a vaginal delivery of twins?  Hmmm…if so, I’d better hold off starting that 5 hour case in the main OR until she’s finished.  See, that kind of thing.

Anyway, my pleasant saunter through LDR in search of information (and possibly cookies), was hampered by the audible rolling of eyes.  See, there was this multip who was about to be induced.  And she wanted an epidural.  Before she would allow an AROM.  Or pitocin.  In fact, she wanted an epidural before she was fully checked in and before the OB on-call had taken a look at her.  Her first labours had been short and she didn’t want to take the chance that she would end up with an unplanned vaginal delivery without effective pain relief.  The nurses, for some reason weren’t happy about this.   Hence the eye rolling.

And the eye rolling was loud.  Maybe the LDR nurses get dry eyes at night from the hospital air conditioning just like I do and that causes their eyeballs to scrape around their eye sockets loudly when they roll them.

They clearly expected me to jump right in there and roll my eyes with them.  Now, I’ve participated in lots of eye rolling.  In fact, when I was a very junior and very smugly ignorantly sure of my righteousness medical student I had to train myself out of eye rolling on the job.  See, some people were, rightly so, getting a little testy that I was letting my personal feelings and biases interfere with developing good therapeutic relationships with patients and rapport with colleagues.  Instead, I said, “it’s a perfectly reasonable request.  Which room is she in?”

The eyeball scraping around the eye socket noise was replaced with a sort of quasi-metallic ping as a few jaws hit the floor.

Anyway, I placed the epidural, which went in like a dream and I thought to myself, “geez, that’s technically a lot easier with having to worry about movement during contractions” and “I feel a lot better about my ability to get truly informed consent from a woman who isn’t experiencing significant distracting pain.”  But those two thoughts aren’t really the point because they are selfishly about me.  What is the point, is that this woman had her epidural.  I injected a test dose to make sure that the catheter wasn’t in a vein or the spinal space but didn’t “load” it.  That way, she would have freedom of movement until she decided she was ready for pain relief.  I told her, and her nurse, that when she was ready, she should top herself off 2 or 3 times via the PCEA (Patient controlled epidural analgesia) button and have the infusion started and if she wasn’t comfortable after that, I would be happy to come by and top her up.

I am not sure where we got this idea that epidurals were a last-ditch resort.  Why does a woman have to be in significant pain before she is felt to deserve one?  Especially this woman who had already had some vaginal births, who had a history of fast labours, who knew what her body felt like during labour and wasn’t particularly interested in feeling that way again.  Could you imagine if I started my anesthetic after the surgeon had started the surgery?  Sorry Mrs Smith, I know it hurts to have your appendix out but with the right support you can get through this with visualization and breathing exercises.  Afterall, the pain isn’t going to last forever, you only need to stand it for an hour or two.

Some possible explanations I think.  We used to use more concentrated solutions in labour epidurals.  Women were frozen to the point where they had significant motor block and that resulted in some obstetrical complications like an increased instrumented delivery rate (forceps and vacuum deliveries) and an increased rate of episiotomy.  Some women (and their babies) developed local anesthetic toxicity from that large dose.  The equipment wasn’t as good back in the day.  Catheters were stiff, complications were more common (anecdotally, according to my more…ahem…senior colleagues).  We still haven’t recovered from the old adage that you shouldn’t have an epidural until you were over 4 cm (or 6 cm if you were delivering in a pretty draconian institution).

Many of these issues no longer exist.  Modern low dose epidurals don’t increase the rates of episiotomies or instrumented delivery.  They don’t increase the likelihood of an c-section.  They don’t slow labour appreciably.  They have a very low complication rate.

Of course, there is also the subtext that a “natural” (read, unmedicated) birth is somehow superior and a goal that all woman should strive for, an attitude that really does run through every LDR I’ve ever worked in.  Maybe the nurses would rather have been midwives.  Or maybe, since this attitude seems more prevalent among the younger ones, they have some trepidation about their own potential births and the epidural procedure itself.  I mean, they get to watch that needle (which is large enough to seem pretty cruel) enter the backs of lots of women and that might add to their unease about needing or wanting one themselves.  The more women you see deliver without pain medication seems to make it more likely, in your mind, that you will deliver without pain medication too.  I wonder about this because the loudest eye roller of the bunch was 7.5 months pregnant with her first child.

The patient, btw, went on to deliver 2.5 hours after I placed her epidural and was very happy about her experience – and I was very happy to facilitate it.

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13 comments

  1. Adequate – may every LDR in the country be blessed with an angel of mercy such as yourself on hand to deliver women from eye rolling and NCB judgement….far too many seem to be lacking the ability to facilitate such ‘reasonable requests’.

  2. I am glad you were able to give her the pain relief she wanted. I am sure she will be forever thankful for you being able to do that.

  3. Interesting read. Thanks for your perspective, and for being there for that mom.

  4. Plump Chaplain · · Reply

    Just two and a half hours!! Yikes, she was right, she DOES have babies fast! Glad you were there for her!

  5. miriam · · Reply

    What did they have to do– wave the pitcocin at her? I’ve always preferred a dedicated OB anesthesia team. OB routinely goes so wrong so fast– pain team can wait, trauma usually has a heads up from the EMTs, airway should have a warning and worst case there is always another service that can help (ENT, CCM)– but no one can substitute for anesthesia, local field blocks notwithstanding.
    Of course I come from an institution where having dedicated OB is both necessary (20 L&D rooms) and possible.

  6. “perfectly reasonable”? No. it was brilliant! It is so much better to get an epidural started when everything is calm, the patient can sit still, there’s very little tension, etc. I tell first-time moms that the fears of epidurals – regarding all the negative possibilities – are outdated if they have an anesthesiologist like you. The “modern” epidurals are safe and wonderful in many ways. Keep up your good work – which is way more than “adequate.”

  7. I have three boringly typical birth stories: labor, epidural, vaginal birth. I needed 1-2 stitches with each. But they’re my stories and they are full of joy. I brought a bottle of wine (the good stuff) in for each birth and toasted my son and then my two daughters. I was able to feel and to push. When I held my baby I was energized, happy and able to celebrate. If the whole “natural” birth works for you- awesome, but this worked for me and I am grateful. No regrets, if you met my kids, you’d see why 🙂

    If

  8. supermouse · · Reply

    I agree with the above poster….there should be people like you in every hospital. I had no problems with getting an epidural–it went much like you described, with getting the catheter and test dose, and then allowing me to decide when I wanted the full pain relief (when things started getting more painful). The doctors and nurses actually encouraged me to have it placed [when they did] because they were starting pitocin. They did have to use the vacuum for Twin A because he was asynclitic, but Twin B came without assistance, so I can personally attest to the fact that women can feel enough to push effectively, assuming the baby is in the right position.

  9. what a heart warming story; thank you for being there for that mother, who knew what to expect and knew what she wanted. It’s much worse to wait 12 hours for anesthetic, then another hour because the ‘ologist was late (remote military hospital), and to get that spinal shot when contractions are so hard and fast that being still is almost impossible. Also worse when the nurse helping you hold still has bad breath. Check your breath before getting nose-to-nose, ladies.

    cheers!

  10. Sounds like my last labor, after two rough attempts at natural in the past (one leading to Fibromyalgia) I was shocked that not only does the epi work better when it happens before the pain started but I also felt soooo much better after the birth. I was not tired and still and sore. I recovered so well. The nurses said I didn’t even look like I had given birth. Pain relief is awesome and so are you!

  11. You rock. This is so spot on.

  12. […] dozed on the couch for a bit I looked around your blog. Among other things I found the post “A Perfectly Reasonable Request“. When I hit 6cm I asked for the epidural even though the contractions were still bearable. […]

  13. Kristen · · Reply

    Love this! What an angel you are! 🙂

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