Friday, August 21, 2009

Labor Pains- Epidural, Neither Demon Nor Savior

A knight in shining armor, the anesthesiologist gallops away on his white horse after saving yet another lady from the throes of pain!

When the epidural works as it is supposed to this or a similar scene is what comes to mind. The fact that the anesthesiologist is the hero in this scenario doesn't bother me. Really, I'm not jealous! Even though un-scientific polls (conducted by me) show that most women would prefer to see their dentist rather than their gynecologist. I know that I will never experience a gyne exam but less popular than dental work? When I see my dentist I have what seems like a large and noisy Black & Decker drill excavating my tooth, shaking me to the core while flying debris land on my face and glasses. This all as I'm trying to watch Oprah on the tiny sized TV mounted high in the corner. It may be my only opportunity to learn what she is telling my patients to ask me. I'm not angry. I'm just sayin'!

Please ignore my digression. This post is not about exulting the virtues of epidurals but hopefully giving you an idea of what we know of it's benefits and disadvantages and perhaps dispelling some myths.

Lets start with benefits:

Epidurals have been shown to be more effective in relieving pain and have less of an effect on the baby than some of the intravenous medications. Their placement is usually easy and despite some women's fears not very painful. Depending on availability some may be able to walk with the epidural in place but in practice most women rest in bed. There is also the possibility of patient controlled epidurals where you control the amount of medication flowing through the pump.

Now disadvantages:

You may have heard that epidurals slow down the process of labor. This indeed appears to be true. Studies show that it can prolong labor by 40-90 minutes. There are also some conflicting data about the fact that it may increase the need for instrumental (vacuum or forceps) delivery.
A more common but usually minor risk is that epidurals can cause a headache. This commonly resolves within days and rarely requires an intervention called a "blood patch".

There are times that epidurals are ineffective or only partially effective. This does not happen very often but understandably can create a great deal of anxiety and panic. Some of my patients say that they want to be "drugged up" so they won't feel any pain. It is important to emphasize the other options for pain relief and provide tremendous coaching and support in case the epidural is unavailable or is ineffective.

How about myths:

Some of my patients make their minds up very early on that they will not consider an epidural under any circumstances. Unfortunately many times this is not a choice based on accurate information but rather myths perpetuated by friends and family members. One of the most prevalent is that epidurals cause chronic back pain. This has been shown not to be the case. The risk of developing back pain is the same whether you receive an epidural or not.

Another common but erroneous perception is that an epidural may not be placed until cervical dilatation has reached four centimeters. The view of ACOG (American College of Obstetricians and Gynecologists) is that "women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia".

Epidural analgesia is a safe and effective option for pain relief in labor. You need to approach this choice as you would any other medical procedure. Ask questions, discuss with your physician or midwife and consider the risks, benefits and other alternatives. This post is certainly not meant to be comprehensive but only to provide an overview and a starting point for discussion. In subsequent posts we will look at some other options to consider and they probably will not involve anesthesiologists or dentists!

To look at the ACOG patient education pamphlet on "Pain Relief During Labor and Delivery" go to:

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