I just returned home from a lecture given by the Chair of our OB Anesthesia Department which I found highly upsetting.
She opened the lecture with her overall purpose: "I want to prepare you for the fact that we are trying to provide care to patients who don't want us to care for them." She said she wanted us to have more preparation before "you are thrown into the lion's den."
Lion's Den? Laboring woman= lion? Really?
DISCLAIMERS
The lecturer gave no disclaimer of her personal opinions regarding labor and delivery management and pain relief but those became quickly evident as one can surmise from her opening statements. I have my own personal opinions, of course, and I have recently had experience with a natural childbirth approach that became surgical. My biases will undoubtedly color what I'm about to write, but I would like to think that I have no personal agenda for other women.
What I wish for the laboring woman is for her to have confidence in her support system, for her to feel that her providers are there to help her, for her to be in a safe atmosphere with skilled, encouraging medical help, and for her baby to have a safe outcome. I think it also reasonable to wish for all of this to happen with very little drama.
Noticed I have said nothing about pain.
PAIN
I am aware that in a number of months I will be the provider who walks into a room to provide pain relief to a woman who may or may not want it. Insofar as my medical training will benefit, I will eagerly jump at the chance to perform epidurals on women who say yes. I will gladly answer their questions to the best of my ability. But if they say no, it won't really matter to me. I have no personal investment as long as the patient has been presented with the options.
My lecturer's approach to laboring pain was this: Why would you not treat it? "Would you do an appendectomy without anesthesia?" She implied it was cruel to NOT provide an epidural. She also cited a study that showed the newborns of natural births had mild alkylosis from their mother's hyperventilation (in an effort, I believe, to prove scientifically that pain is bad... and you can't dispute science, right?), yet she failed to prove that a transiently high pH would have any adverse outcome on a baby.
There is no dispute about laboring being a painful process, yet I think it is important to let women decide what is allowable for themselves. Some women go through it and feel more confident and proud of themselves for having "made it." Great. Some women have such relief from an epidural that their birthing is a more pleasant experience. Great.
The point, again, is that is is not for me to decide.
The odd thing is that in all of my other pain lectures, we have been taught to focus on the fact that pain is made worse by human suffering. We are advised to approach patients not with the intention of erasing their pain, but with the intent of helping them to manage the suffering (depressed mood, lack of sleep, anxiety) that accompanies pain and makes it worse. The new goal therefore, is to help a patient "pain better."
Why, then, are anesthesiologists only able to offer laboring women epidurals and spinals as the only tool in our pain-relief toolbox?
EPIDURALS-New data
Ok, the one helpful thing in the whole lecture what dispelling some myths about epidurals. It turns out we've gotten a lot better at them. In the last ten years, we've started to use a really light concentration of local anesthetic and we use a miniscule amount of fentanyl; basically, just enough to have an effect on the spinal cord without effecting the blood or the baby. The result is epidurals that don't totally numb the patient, making it easier to be strong and push. The is, of course, at the expense of getting complete pain relief. So, at best epidurals take the edge of off pain (and we're taking the contraction pain, not the pushing pain because epidurals don't even touch the perineal area at all).
Secondly, because of this decrease in the medication concentration it has now been shown, repeatedly, that epidurals do not slow labor and do not lead to more c-sections. In fact, many studies show that they decrease laboring time. (The same has also been proven for having a doula present in the room...hmm...) The lecturer's point was epidurals are safe in early labor and should therefore be placed in early labor. Why? Because it's more convenient for us. I'm sorry, but I'm really wary of doing anything just because it's more convenient for my work schedule. Unless a woman wants an early epidural, you won't find me pushing one on her...
WTF?
So, the lecture gave me some new factual data on epidurals. I'm sure that will come in handy at some point. But if the overall purpose of the lecture was to prepare us for "patients who don't want our care," I think it failed miserably because instead of placing us in the shoes of a laboring woman, she puts us at odds with them.
My lecturer seemed to think that women who refuse pain relief or women who desire a home-birth are not concerned about their health or what's best for their baby's health. She essentially implied that pregnant women can't even think logically. While there are, most likely, exceptions, I think most people would agree that mother's-- more than anyone-- want what's best for their babies.
So one must ask the question, Why are women so mistrustful of their birthing experience? If they are not thinking "logically" and listening to our "science," what is making them so emotional?
To even begin to discuss women's health and laboring health in particular, I think one has to acknowledge that is is political, just as much as it is personal (Note, the recent fall-out over the word "vagina" used on the congressional floor). Our current practices and beliefs are part of the legacy of medical care that came before us.
For example, during my medical education in the south, we talked a lot about race in the context of healthcare. How could we not? We worked in a hospital that some locals still call "The Gradys", plural, because Grady Hospital used to be segregated into two separate hospitals. One cannot even practice medicine there without knowing about the Tuskegee experiments (performed on African-American men with syphilis, during which a cure was found but withheld from the research participants) and how that contributed to a growing mistrust of the medical system.
Similarly, in the last century, women have also been the subjects of the medicalization of birthing. Don't get me wrong, I don't think medicine is the enemy. There have been fantastic advances in medicine that have made many birth situations, particularly for high risk moms and complicated babies, much safer than before. But I'm not convinced that the average experience of otherwise-healthy women has improved much. In our efforts to make women and babies safer, I think we have to acknowledge that a lot of women came to more harm than was necessary whether psychological (ether births) or physical (induced labors, unnecessary c-sections, unnecessary repeat c-sections).
There is a reason many women feel like they get bullied during their laboring experience.
And it's called "The Business of Being Born."
No, just kidding, I watched that video and while I don't think it's a 100% accurate depiction of the medical world's view towards birth, I like that it encouraged women to educate themselves about birthing options and advocate for their plans. Ultimately, though, it IS about preserving the health of a newborn and I don't think we should sacrifice that for our personal and political agendas (oops, now I'm referencing my own birthing experience!).
SUGGESTIONS
So what do I do now? For now, I slap a fake smile on my face while I work with this woman who seems like she wants to use science data to argue women out of decades of medical harm and hurt.
In the interim, I'll be dreaming of a birthing experience in which anesthesiologists offer more than needles and local anesthetic. Maybe we can be more involved in the prenatal education classes so we can dispel myths about epidurals so we aren't viewed as evil needle-pushers, stooping over contracting women, waiting for them to cave into our plans. Maybe we can partner more with doulas and promote massage and acupuncture and other methods to reduce stress and pain.
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I have a feeling that when it comes to satisfaction with one's laboring experience (and yes, I am speaking from personal experience) that women care more about the kindness and comfort they received from their healthcare providers than the precision of their pain relief. We all know labor's going to hurt on some level, epidural or not. Maybe anesthesiologists, instead of rolling their eyes, can offer women words of moral support and encouragement when they choose to forgo an epidural.
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