Epidurals - the Good, the Bad, and the Ugly

Reading the book review by Dr Harriet Hall on SBM regarding pain relief in childbirth made me stop and think. Like breastfeeding, epidurals seem to be a tender point. So, let's talk about them.

First, let me say that I am one of those women who didn't have an epidural, has never had an epidural. Why? Because I have a phobia. I am totally, irrationally afraid of needles going into my spine. Even when suggested for non-childbirth related procedures, I panic too much. As I said, totally irrational.

Let me preface this by saying most anesthesiologists are fantastic. It can't be easy to put an epidural in. I admire their ability to perform their job, even when they are "trying to hit a moving target".

The Good: a good epidural is one that has been discussed in advance and agreed upon (as either a definite choice or a possible choice) by the patient and her care giver. She is aware that an epidural provides pain relief but she will probably still feel touch, pressure and temperature changes. (Personally, I would like to know more about the 'walking epidural' that supposedly women get in some European countries. It sounds like a win-win situation - pain relief without immobility). These women may or may not have problems with the epidural - spinal headaches being the most common - but they are happy with their choice.

The Bad: a bad epidural is one where the patient has irrational expectations. I have seen women be very distressed that they feel anything at all. They may be totally numb to pain, but since they feel pressure and touch, they often feel betrayed because they were "promised that they would not feel anything." In this category also falls the epidurals that "don't quite work". Some women do not get pain relief, others get pain relief in all areas but one (a window, we call it). I always felt very bad for those women; it seemed that having only one area feeling pain made the pain much worse. These women feel very betrayed and are unhappy with their choice.

The Ugly: my category for a physician-ordered epidural when the patient does not wish to have one. The one instance that stands out in my mind: a woman came in to the hospital in labor, dilated 9 cm. She was coping and did not wish any pain relief. When her physician was informed of her admission, he ordered an epidural (All of his patients ended up with epidurals). The patient did not want the epidural and, due to her very advanced stage of labor, the nurses called the OB resident who delivered the woman shortly thereafter. The attending was irate when he arrived and found the patient had not had the epidural. He tried to write up the nurses for "disobeying his order". Only the intervention of the anesthesiologist on call, who stated that he would not have given the epidural anyway, saved the nurses. These epidurals were rare.

However, before I left OB nursing, I found more and more commonly that patients were being told "they would get an epidural as soon as they came in." Some women were very happy with this. Others, who had plans for natural, unmedicated childbirth until they learned late in their pregnancy that their OB really didn't support this, were quite unhappy. So, here were the good and the ugly.

I always felt epidurals had their place. I strongly believe that not every woman needs one, but that they should always be an option. Personally, I would like epidural to be the last option for pain management instead of the first, but that's the midwife in me speaking. I never talked a woman out of an epidural. On a few occasions, I did talk women into having an epidural. Rare occasions and generally extenuating circumstances.
(In one place I worked, there was a very toxic childbirth instructor who preached that pain medications lead to mental retardation and epidurals caused fetal death. Her students were very hard to care for if they were unable to cope with labor contractions using the childbirth techniques. We tried to steer women away from classes with her; there were other instructors who taught the same method without the hyperbole whom we recommended. Many of those instructors were 'on-call' for us if we got toxic-teacher's students in who really needed pain relief. They would give the student permission to get the pain relief - TT also convinced her students that they needed permission from the instructor for it!)

Rather a rambling post. So, epidurals. Good, bad or Ugly? What has been your experience?