As an L&D nurse, one of the first questions we ask of our patients during their admission interview is if they have a birth plan and what their plans are for pain management during labor. Here are the 5 most common responses to that question:
#1 I would like to have a natural/unmedicated childbirth, Please do not offer me any medications/epidural because I will ask for them if I decided I need them.
#2 I am pretty sure I want to have a natural/unmedicated childbirth, but I haven’t ruled out the possibility of any medications/epidural because I don’t know what to expect. However, I’d like to go as long as possible without them.
#3 I definitely want pain medication but I do not want an epidural because:
a. I don’t like the idea of a needle in my back,
b. My best friend/sister had a horrible experience with it.
#4 I want an epidural as soon as I can have one but I want to try to avoid pain medication because:
a. I heard it can make you feel out of it/loopy,
b. My best friend/sister had a horrible experience with it.
#5 I want everything and anything you can give me as soon as you can give it to me…I don’t want to miss my “window” for an epidural either! Can’t I just have the epidural now?
What I have always found interesting is that except for some women who answer #1, I rarely hear reasons for not wanting either pain medication or an epidural that include the very real risks of:
“Because it can negatively affect my baby.”
“Because it can negatively affect me.”
“Because it can negatively affect my labor progress.”
“Because it can negatively affect my chances for a vaginal delivery.”
After hearing the mothers’ responses and if time allows, I typically ask them how they prepared for labor and childbirth and how they came to their plan of wanting or wanting to avoid pain medications or an epidural. Not surprisingly, the most common responses for women who answered #2 through #5 are: “I only took the hospital tour/childbirth class,” “I only read ‘What to Expect When You’re Expecting’”, “I only talked to my other friends/family who have had a baby,” or “I didn’t do anything really.”
I am going to be quite honest here. It pretty much baffles me that women who are planning on utilizing pain medication and/or an epidural during labor typically have not learned much more about them besides when they can be given and how they are given. That is, in my experience as an L&D nurse, the RISKS of the procedure are rarely if ever fully understood and the BENEFITS are often exaggerated. Whenever I get the chance, if I feel that a woman has not researched the risks and benefits of pain medication/epidural during her pregnancy, I will try to go over them fairly and accurately if time and circumstances allow. I typically only get this chance if they are being admitted for an induction. On the contrary, if they come in during active labor and are very uncomfortable, I try to do my best to explain risks and benefits but I also struggle with trying to be sensitive to the fact that they are uncomfortable and probably aren’t or can’t completely pay attention to everything I am going over. It’s really quite the predicament.
I guess what I am trying to get at is that women need to start taking control of their own bodies and health care decisions. The fact of the matter is, “TRULY INFORMED CONSENT IS ONLY POSSIBLE BY CONSUMER INITIATIVE. PERSONAL EDUCATION IS A PERSONAL RESPONSIBILITY.” ~ David Stewart, founder and director of NAPSAC***
What does that mean you ask? To me, this quote means that true informed consent is only accomplished and insured when the health care professional (e.g. obstetrician, anesthesiologist and sometimes even the midwife or nurse) AND the consumer (i.e. the pregnant woman/childbearing family) are BOTH active participants in the informed consent process.
Regarding the role of the health care professional, the American Medical Association defines informed consent in the following way:
Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. In the communications process the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with [the] patient:
(1) The patient’s diagnosis, if known;
(2) The nature and purpose of a proposed treatment or procedure;
(3) The risks and benefits of a proposed treatment or procedure;
(4) Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
(5) The risks and benefits of the alternative treatment or procedure; and
(6) The risks and benefits of not receiving or undergoing a treatment or procedure.
In turn, [the] patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.
Now that you are informed about the role of your health care provider, I would like to remind all consumers of health care that might be reading this blog (i.e. pregnant women/childbearing families) that if you forfeit or ignore your personal responsibility to educating and preparing yourself for pregnancy, labor, childbirth, and postpartum, then IT IS YOU THAT HAS TO LIVE WITH THE DECISIONS YOU LET YOUR HEALTH CARE PROVIDER MAKE FOR YOU! David Stewart writes,
“Professionals do not always have the best answers. This is not a criticism of professionals, but a simple recognition of the fact. It serves neither professionals nor patients to disregard this fact. All have limited experience and limited education. The best health care is available to consumers who participate in medical decisions pertaining to themselves and their families. …To be fully informed requires preparation and education before [the fact]. Doctors and medical institutions have a clear obligation to assist patients by providing unbiased pros and cons of policies and procedures. They do not have the obligation to be a patient’s sole and complete source of education.”***
I know I would be better able to sleep better at night if more of my patients who come in requesting an epidural/pain medication (or really any labor intervention for that matter) have actually done their own personal research on the risks and benefits of the procedure and have made their decision based on a complete set of facts as opposed to just coming into the hospital requesting an epidural with the only “education” obtained on the matter being “my sister said she had one and it was awesome/nothing bad happened so I want one too.” Ugh!
One circumstance that I always find particularly bothersome is the fact that at many hospitals (including my own), the woman is typically signing the Consent for Anesthesia (which has to be signed with the anesthesiologist in the room) when she is extremely uncomfortable and demanding an epidural be given immediately! So even if the anesthesiologist properly reviews all the risks and benefits with the patient, she is typically not listening, telling us she is not caring, and signing the consent without even reading it over. Since I often feel as if I have little influence over this fact (I don’t always get the chance to show the patient the consent for anesthesia to read over when she is comfortable), I would like to take this opportunity share with all of you an actual hospital Consent for Anesthesia that is used for labor epidurals and cesarean anesthesia (including spinals and general anesthesia) so that you may read it over in the comfort of your own home and maybe even discuss it with your birth attendant and labor companions way before you ever feel your first contraction.
I consent to the administration of anesthesia under the direction of an anesthesiologist and to the use of such anesthetics and techniques as he/she may deem advisable. I understand that anesthesia residents and/or certified nurse anesthetists may be involved in my care under the direction of the assigned anesthesiologist. I understand that the type of anesthesia and/or the assigned anesthesiologist may have to be changed during the procedure due to changing circumstances.
The anesthesiologist has fully explained to me the risks and discomforts that may arise as a result of the proposed administration of anesthesia, as well as possible alternatives, for my labor/procedure. I have been given an opportunity to ask questions, and all my questions have been answered fully and to my satisfaction. The risks discussed include, but are not limited to: headache, nausea, pain, vomiting, aspiration, dental or voice injury, awareness during anesthesia, heart or breathing complications, unanticipated or prolonged hospitalization, blood clots, infections, adverse drug reactions, I.V. infiltrations, nerve damage, paralysis, blindness, brain damage, and death. Since I am pregnant, I understand these risks extend to the unborn child I carry. I understand and acknowledge that no guarantees or assurances have been made to me concerning the outcomes from the administration of anesthesia.
I confirm that I have read and fully understand the above prior to my signing.
(Patient signature/legal representative)
Do you know what you’re signing?!?!
In conclusion, as you prepare for your labor and childbirth experience, it is very important to remember that it is ultimately YOUR OWN responsibility to become educated on your options regarding pain management, including both non-pharmacological as well as pharmacological interventions. Likewise, waiting to “learn all about it” once you get to the hospital is not very responsible. It is also important to remember that any pharmacological intervention, including pain medications and epidurals, carry many risks to both you and your unborn baby and therefore you owe it to your unborn baby, your partner, and all of the people in your life that love you to LEARN about it before you consent to it. Like author Henci Goer, one of my goals in writing this blog is to never hear another women ever say, “But I didn’t know that was a risk” or “I never would have agreed if I had known that could happen.”
For fair, balanced, research-based facts and information about pain medication and epidural use in labor please check out the following resources:
- By Dr Sarah J. Buckley MD’s Epidurals: risks and concerns for mother and baby
- American Pregnancy Association’s Using Narcotics for Pain Relief During Childbirth
- American Pregnancy Association’s Epidural Anesthesia in Labor
***As quoted on page 137 of Silent Knife by Nancy Wainer Cohen & Lois J. Estner. NAPSAC stands for “National Association of Parents and Professionals for Safe Alternatives in Childbirth”