What do you want your OB patients to get from childbirth class?

kmchugh · Apr 11, 2005

kmrmom42

My hat is off to you. I went to your website, and think you gave a pretty accurate representation of epidural and spinal anesthesia. I have talked to a couple of moms who thought epidurals were all sunshine and lolly pops with no dangers to them at all. As the guy who puts the epidural in, nothing makes me more nervous. I spend a bit more time talking to these moms, making sure they understand that nothing done in medicine is risk free, particularly epidurals.

I did notice a few things in your website that could be changed (I am forever trying to make sure patients and provicers get the most up to date information available.)

Cynthia Wong, MD, did a study on the effect of epidurals and labor, and found that as a rule, having an epidural shortened the length of stage one of labor. It also seemed to slightly prolong stage two of labor, but that was more than offset by the shortening of stage one. She also found that the use of labor epidurals did not increase the incidence of instrumented birth or c-section. See the following thread in the CRNA board:

https://allnurses.com/forums/showthread.php?t=99466&page=1&pp=10

Also, one thing I like to pass along to just about everybody who will listen: General anesthesia is absolutely the last resort for an anesthetic for a c-section. Nothing will make an anesthesia provider break out in a cold sweat faster than the prospect of having to put a pregnant woman to sleep. Pregnant women have a much higher incidence of GERD, with the attendant risk of aspiration than the rest of the population. Also, there is a significantly greater risk of failed intubations among the pregnant population, generally owing to the fact that pregnant women are edematous everywhere, making inability to visualize the cords a much greater risk. Babies of moms who have a general also come out "floppier," owing to the systemic administration of anesthetic induction agents. As a rule, we only put women to sleep for c-sections under emergent circumstances, those where waiting the few extra minutes for placement of a spinal or epidural anesthetic could detrimentally affect either mom or baby.

I have had a couple of moms for scheduled c-sections come in absolutely refusing spinal or epidural anesthesia. Whenever that occurs, I have a LOOOOOONG talk with the patient about the increased risks of a general anesthetic. Of course, I never perform any procedure on any patient who refuses it. But, if the parturient insists on a general anesthetic, I will go the extra mile to make sure emergency airway equipment is in the room, and will try where ever possible to have another anesthesia provider present until induction is complete and the patient is safely intubated.

Overall, though, I think you did an excellent job of presenting options for pain management through your website. I also found the Discovery Channel website that you referenced on the topic of epidurals to be very informative for the patient. (See:

http://health.discovery.com/tools/blausen/conditions/epid.html

it offers a great graphic.)

The point about length of labor is relatively minor, and I know that there are those who will beat me up for saying that epidurals can decrease the length of labor. I do feel very strongly about general anesthesia for c-sections, however, and would never want it presented to pregnant women as an equally safe method of anesthesia for c-section.

On my soapbox for a moment (not directed at anything written by kmrmom42): In other threads on this board, it has been insinuated that anesthesia providers push epidurals for laboring women for billing purposes. At one time, that may have been true, but not anymore. The reimbursement for epidurals is very low, compared to the amount of time the anesthesia provider will generally have to spend at the hospital managing that epidural. From strictly a cost analysis, they certainly are not worth the effort. We don't offer them to "get rich" by any means. In fact, most hospitals that offer them do so realizing that they will actually lose money on them. The reimbursement for them comes nowhere near what they cost the hospital (or anesthesia group) in equipment, medicine, and provider time. This is particularly true in smaller hospitals, where there is frequently only one or two laboring women.

Off my soapbox (for now).

Kevin McHugh, CRNA

kmrmom42 · Apr 11, 2005

kmrmom42
My hat is off to you. I went to your website, and think you gave a pretty accurate representation of epidural and spinal anesthesia.

Thank you Kevin. I value your opinion.

I have talked to a couple of moms who thought epidurals were all sunshine and lolly pops with no dangers to them at all.

I agree this is dangerous and I am the person who wrote the curriculum for our Prepared Childbirth classes (and I currently teach them all myself although I am looking for help!). I am very careful to teach that epidurals, like most things in medicine, are not risk free. I include epidural as one of the "tools" for coping with labor and after finishing my classes couples have MANY tools in their labor toolbox besides epidural.

Cynthia Wong, MD, did a study on the effect of epidurals and labor, and found that as a rule, having an epidural shortened the length of stage one of labor. It also seemed to slightly prolong stage two of labor, but that was more than offset by the shortening of stage one. She also found that the use of labor epidurals did not increase the incidence of instrumented birth or c-section.

Thanks so much for this. I AM aware of this information and I can tell you that I see this as being true in my every day practice. This is DEFINITELY going to be one of the things I update on my website. I am sure you will agree that epidurals used to be much heavier and they did cause these sequelae but now that is no longer true.

Also, one thing I like to pass along to just about everybody who will listen: General anesthesia is absolutely the last resort for an anesthetic for a c-section.

I agree wholeheartedly and teach this way in my class. I always have someone ask if they can request general and so it opens the discussion in which I am VERY clear about this. I will add something to my website to that effect when I revise.

The point about length of labor is relatively minor, and I know that there are those who will beat me up for saying that epidurals can decrease the length of labor.

One of the reasons that the epidural may decrease the length of labor is because once the patient gets the epidural we are very likely to use pitocin to insure that it does!

Thanks so much for viewing my website and for your thoughtful comments. As I said, I value your opinion.

Have a great day! Karen

SheaTab · Apr 11, 2005

"but in the long run, your patients are going to go along with what the doc pushes anyway."

True True True!!! I had a mother a few weeks ago labor for hours and hours because her MD (infamous for inductions!) wanted to induce her. It was her 5th baby!!!! Her cervix was green as a granny smith apple. Inductions are my pet peeve. I understand they are necessary in RARE cases, but not as a rule! AND, a lot of the time, women are more than willing to be induced because they are tired of being pregnant and are excited about meeting their baby. However, FAR too many c-sections are performed because of "failure to progress." Which, in most cases, means that her body simply wasn't ready! So this generally means repeat c-sections because this woman will believe that her cervix simply isn't capable of dilating past 4 cm which is RARELY the truth! I had a section and then a VBAC, and I can tell you definitively that the vag delivery was a BREEZE! LOVED IT! Even though I had a HUGE episiotomy, I still LOVED it! Episiotomies are my next gripe!

They are also rarely necessary. The research shows that a tear heals better, usually isn't nearly as extensive as an episiotomy...etc. etc. Episiotomies increase risk for infection, are very painful, can also increase risk for painful sex, fecal and flatus incontinence and formation of fistulas. Now, don't get me wrong, they are necessary in some cases, but not as a rule. We are a high intervention hospital and a lot of our physicians do them all the time. I would say that 98% of our primips walk out the door with one! It infuriates me. Tell your girls that her body belongs to her and that she has the right to refuse any treatment. Our doctor's will tell our girls... "looks like your going to tear and you don't want to do that. I'm going to cut a little episiotomy to prevent it, OK." As if that is informed consent! I want to say "NO YOU DON'T want an episiotomy... it is better to tear a little bit!" I have seen way too many physicians basically perform lady partsl c-sections. Tears are much more likely to be first degrees. I never ever see an MD cut anything less than a 2nd degree and those are likely to extend. So tell your patients that they are an unnecessary procedure for the most part and that they should refuse them unless they are given information about why it is VERY necessary in their case! Fetal distress is one such indication.

Epidurals... some women seem to have the impression that they should be completely paralyzed!!! And, if they are not then it must not be working properly. The perfect epidural is one in which the patient can still move her legs and yet her pain is relieved. Also great is if she can feel pressure as she becomes "complete." This will help her to push! I have so many patients scared that they can still move their legs because they are worried that the birth will be painful. Pressure and leg movement are good things. I had a patient tell me the other day that she had never been told that it might be more difficult to push with an epidural. In some cases that it very true! Especially where I work because the anesthesiologists dose them up big-time! We do MANY more forceps deliveries than I believe a lot of other geographical areas do because our girls simply can not feel to push. I read the post about Wong's study which found that increased instrumentation was not related to epidural use but I have to disagree in my case. She DID NOT do her study in my facility! I can tell you that about half of my girls push for 1.5-2 hours and a good number of those end up with forceps! Sad sad.

Also, tell your girls that they do not have to agree to a c-section. Our physicians do them all the time because they have a party or engagement of some sort to go to and when 5:00 pm roles around, they need to be out the door. It is ridiculous. If the patient is not progressing, time may cure that. Why rush things unless fetal distress or another serious problem is clearly evident. A lot, but not all, of physicians prey on a woman's ignorance and will do a lot of unnecessary procedures for their personal convenience.

I truly hope most other labor & delivery units are not like mine! We are one of the largest in the country and are the choice facility in the area because it's like delivering at the Ritz Carlton... Women need to know that they do have choices!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

>>>

YES!!! I second this! AND, please, explain the pain scale. I love it :uhoh3: when patients come in smiling and talking and call their pain 10 (on a scale of 0 to 10). I just want to cry for them and myself when I find out that they are only 1-2 cm. They have no idea what is going on! 10 on the pain scale is like being set on fire!!!! "Now, are you really a 10?" Or, how about those women who SCREAM continuously as if their pain has no end. These women, in particular, need to know that we will not keep them if they are not in labor. Doesn't matter how loud they scream. YES... we have had women come in by ambulance, screaming down the hall, saying they need to push... check their cervix and they are 1 cm! I tend to note here that this is a woman who has not had childbirth education classes! Don't get me wrong, a woman screaming in pain like this warrants more thorough assessment. Like... kidney stone??? Major other physiological alteration?? For the most part, when you tell them they are only 1 cm, they stop all the carrying-on though. I think they are kind of embarrased. I would be.

Good luck!

Tabitha

nursey_girl · Apr 26, 2005

I would like my patients to know why we do some of the things to do and not rush to refusal. Like IV's and Monitoring. I would like them to realize that birth plans don't always work ( Usually the opposite happens), and I wish that they understood how families, even though they may be well meaning, can actually be a hinderance to good care. It's frustrating to keep the families away from the doors while were delivering, it's also a safety issue. It's difficult plowing though the families to go to the baby because it's blue following a birth.