Thoughts on epidurals, risk, and decision making

In the Winter 2012 issue of The Journal of Perinatal Education I read several interesting tidbits related to women’s experiences of medication during labor, expectations for birth, and thoughts on risk and choice. In an article by Hidaka and Callister titled, “Giving Birth with Epidural Analgesia: The Experience of First-Time Mothers,” I was struck by one mother’s explanation of why she “chose” an epidural: “‘I was nervous about lying down and being confined to the bed again.'” As the researchers explain, “She wanted to stand or sit to cope with labor pain; however, many times she had to lie down for monitoring, and that position made her pain worse, so she was inclined to opt for an epidural” (p. 29).

Some questions immediately arise here. Did this mother actually want an epidural? Do women really need to lie down to be monitored? Was normal labor unbearable without medication? Did she make a free choice? The answer to all is, no. In this case and in so many others around the nation every day, the physiologically normal and fully appropriate need for freedom of movement during labor ran smack into the hospital’s expectation of stillness. And, medication was a consequence of that stillness, not an inability to cope with normal labor–it was an inability to cope with enforced passivity that was directly counter to the natural urges of her birthing body. Where is the “opting” here? When birthing women are literally backed into corners, no wonder epidural analgesia becomes the nationally popular “choice.”

Risk and birth

In another article titled “Risk, Safety, and Choice in Childbirth,” Judith Lothian explores our risk-driven obstetrical model, drawing on material from Raymond De Vries who, “describes that the common strategy of professional groups gaining control is to create risk or exaggerate risk. One ways groups gain power is by reducing risk and uncertainty. Where there is limited risk, it can be ‘created’ by redefining ordinary life events as risky and emphasizing whatever risk exists. The medical model encourages women to see birth as inherently risky for mother and baby…The obstetrician is then in the powerful position of reducing the risk and uncertainty. During pregnancy, women are advised and cautioned about every conceivable, however small, risk; but interestingly, when it comes time for the birth there is little, if any, discussion about the risks of routine interventions, such as continuous electronic fetal monitoring, elective induction, and epidurals…” (p. 45-46).

What are the implications for childbirth educators and doulas? We need to be cautious of perpetuating a medically oriented model that implies that women are responsible for minimizing all possible risks during pregnancy and yet then accepting a climate for giving birth that actually increases risks for both mother and baby. Lothian notes that educators must make it clear “that the current maternity care system increases risk and makes birth less safe for mothers and babies. Women need to know the care practices that make birth safer for mothers and babies and the practices that do not.” She goes on to address a key point, stating that “Childbirth educators need to take a strong stand in support of changing the system to increase safety for mothers and babies…safety is not about frantically trying to minimize small or exaggerated risks during pregnancy and then giving birth in hospitals that protect obstetricians’ interests while increasing risk for mothers and babies” (p. 47). [emphasis mine]

Storytelling and birth

In a later article by Barbara Hotelling about styles of teaching about medications in birthing classes, she references Lothian who suggests, “childbirth educators replace in-depth discussions of stages and phases of labor, medical interventions, hospital policies, and complications…’Let go of trying to fit everything in. Women don’t need to know everything about labor and birth.'” What to do instead? She suggests replacing traditional forms of education with storytelling and other strategies that recall how women through the ages have traditionally come to know and understand birth, stating that, “‘Storytelling is a powerful way to convey basic information about physiology, coping strategies, and confidence'” (p. 51). I’ve written before that what women need isn’t actually just more information and to get educated and these experienced educators agree, “Now there are many books, videos, YouTube videos, and magazines that give expectant parents the information. In their classes, childbirth educators can add storytelling from friends and family about their experiences with pain medication during labor and birth, allowing educators and their class participants to learn from the wise women who went before them” (p. 51).

I’ve long sought ways to help parents cultivate their inner knowing and body wisdom and to focus classes around the development and enhancement of personal resources, rather than on simple information sharing. I would like to re-vision my own approach to childbirth education into a cooperative, woman-to-woman, birth circle type of environment. Michel Odent describes this in his book Birth and Breastfeeding as “new style” childbirth education: “for the most part, these are mothers who have no special qualification but, having given birth to their own children, feel the need to help other women who could benefit from their personal experience. They organize meetings, often at their own homes. They do not usually encumber themselves with any particular theoretical basis for their teaching, but may find it useful to give this or that school of thought as a reference. Their aim could most accurately be described as being to provide information and education, rather than specific preparation.”

Addressing the subject of pain…

Returning to the first article quoted above, in their discussion, Hidaka and Callister state, “Our findings confirm those of a recent systematic review of women’s expectations and experience of pain relief in labor. Across studies, women underestimated the pain of childbirth, we’re not prepared for the intensity of the experience, and often had unrealistic expectations” (p. 29). I’d like to address the other points in a future post, because I think they are very significant, but for now they offer several good tips for childbirth educators to address the topic of labor pain during birth classes:

  • Teach that some pain/sensation has a purpose to alert the laboring woman to the need for movement, doing something different to encourage rotation and descent, or to push
  • Teach that the sense of empowerment for accomplished tasks and goals cannot be replaced only with pain relief
  • Teach that perception of pain is different for every woman
  • teach that every situation is unique so that no single pain management strategy works
  • Teach that the word labor means “hard work” and not “big pain”
  • teach that labor contractions intensify until about 5 cm, and that other sensations (e.g. “downward pressure”) may seem scary or painful
  • Teach that the sensations of labor are not all unique to labor (e.g. bad menstrual cramps, back pain, nausea, pressure)–they have lived through these experiences before

Related posts:

The Illusion of Choice

The Value of Sharing Story

Practical Ways to Enhance Knowledge for Birth

Information ≠ Knowledge

Women and Knowing

Asking the right questions…

5 thoughts on “Thoughts on epidurals, risk, and decision making

  1. “Teach that the sensations of labor are not all unique to labor (e.g. bad menstrual cramps, back pain, nausea, pressure)–they have lived through these experiences before”

    I think this is particularly valuable because so many women express to me that they are scared of the unknown. Reinforcing that they already have experience with similar sensations or the same sensations in less intense forms will go a long way to dispelling some of the generalised fear a lot of first time mothers have.

  2. I really like the idea of birth classes being taught through storytelling. I took a class as well as watch a birth course on DVD and I don’t remember a whole lot about it. I vaguely remember the generals but didn’t once think about it while I was in labor. On the other hand I clearly remember the birth stories women told me- both medicated and natural. I think stories soak in deeper and stay with us longer. I think they are also more likely to be remembered when most needed.

  3. Apparently I already read and commented on this post but in rereading it today took something different out of it. My thoughts are less relevant today but focus more on the story in the beginning – about the woman who ‘chose’ the epidural because the pain of lying still to be monitored was so difficult to manage. This was my experience with my third – I was in the hospital which I wasn’t thrilled about since my second delivery had been a home birth that had been a great experience. We had reached a number of compromises with the hospital staff but they still wanted to monitor every hour for fifteen minutes. My nurse was great at leaving us alone for hours at a time but each time she needed me to lay down so she could get a good read on the baby was agony. Because my boy was positioned differently it was almost unbearable to lay down and I was about ready to ask for an epidural by the time they were done. I think my previous experience and support from my doula and husband made the difference in knowing that I could get through those difficult contractions. It reminded me that it’s not just that every woman labora differently but also that babies bring their own uniqueness to the equation as well. Forcing all women with their various combinations of body type and babies to fit one routine is absurd. My friend preferred to labor sitting in her bed. Generally I need to be on hand and knees to take the weight off my back. Sorry to ramble but had to throw my two cents in. 🙂

  4. Pingback: 2012 blog year in review | Talk Birth

  5. Pingback: Tuesday Tidbits: Birth Conditioning | Talk Birth

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