Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Consent for Anesthesia: Do You Know What You Are Signing? May 5, 2009

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.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Anesthesia Consent

 

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:

 

 

 

 

_______________________________________________________________________

***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”

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52 Responses to “Consent for Anesthesia: Do You Know What You Are Signing?”

  1. Kathy Says:

    I’ve heard of a hospital refusing to give women epidurals unless they took a special pre-labor class on epidurals, which I thought was pretty good… but I found out about the restriction after it was lifted — I’m guessing that women complained about not having that as an option if they couldn’t make time for the class. I’d also assume that the reason for the class in the first place was a liability issue — so women couldn’t complain when the epidural went wrong in some way.

  2. Amy Romano Says:

    Thank you for this! I agree that many women only think of the benefits of pain relief versus the “risk” of getting to the point that the pain is unbearable, rather than approaching the decision as one that can affect the likelihood of a healthy and safe birth. I also think, as Penny Simkin has said, that women equate pain with suffering, when in fact you can suffer without pain or have pain without suffering. The only women I know who had unmedicated births and feel that they suffered were those who expected an epidural and didn’t get it because labor was too quick or the anesthesia staff were tied up with other patients.

    It’s interesting that one of the “risks” I hear about most often is the “risk” that the epidural (or the narcotic) won’t work. Again – this has nothing to do with a reasoned consideration of the actual health and safety effects. Women need to know the potential downstream effects of an epidural, particularly the effect on her likelihood of needing forceps/vacuum; the risk of being separated from her baby because of a fever in labor (so the baby can have a sepsis work-up – which may include a spinal tap); and the increased need for pitocin to speed up labor, among others. It doesn’t mean women can’t still decide to have epidurals – I’m a home birth midwife and I’ve had several clients for whom I strongly believe the well-timed epidural preserved their chances of a vaginal birth. But the conversation between care providers and women needs to happen much earlier and over a longer period of time and be more nuanced and complete. One of the times recently when a client had an epidural, I could have sworn the anesthesiologist was trying out for that Pepto Bismol ad: “Nausea, Heartburn, Indigestion, Upset Stomach, Diarrhea!” (Except it was, “backache, headache, infection, won’t work, will only partially work, may slow down pushing!”)

    • nursingbirth Says:

      Amy Romano, thank you so much for your comment and I have to SECOND THAT to everything you said! As you stated the risks of these interventions are very real and the worst risk isnt just that it “wont work!”

      Also you write, “I’ve had several clients for whom I strongly believe the well-timed epidural preserved their chances of a vaginal birth” and that is exactly how I feel sometimes. As I stated in my blog post “My Philosophy: Birth, Breastfeeding, and Advocacy” I am not anti epidural, but I do consider them a medical intervention and hence I advocate for the appropriate use of them. So that does not mean rushing aroundt to get a patient an epidural when they come in at 9cm screaming for relief! (And yet I have had some doctors actually yell at me to “get the patient what they want!” Jeeze! How about giving her support!! Also, I have always said I’d rather a woman have a vaginal birth with an epidural then a cesarean section without one (considering that you end up with at least a spinal for the cesarean anyways!) but again it has to be well timed, truly necessary, and appropriate. P.S. I love the Pepto Bismol reference! Haha!

  3. feedingtimeatthezoo Says:

    I had an epidural w/ my first and was very uninformed. Later I went to review my medical records and was *shocked* to realize that I’d been given Pitocin. I was never asked and I was completely unaware that I’d had any. I guess when I “consented” to anesthesia I “consented” to any and all medical procedures down the line? Angry and violated does not even begin to describe how I felt.

    Needless to say my other 2 were born 100% drug free. And it was *awesome* 🙂

    • nursingbirth Says:

      feedingtimeatthezoo, I am too shocked that you were given Pitocin without your knowledge. Unfortunately I have heard of that happening before. And for the record you did not give a blanket “consent” when you consented to anethesia, you are RIGHT to feel violated!! Your right to informed consent was not granted for the augmentation! Also I am so glad you had an “awesome” experience with your second two kids! I always feel that childbirth, especially an unmedicated natural vaginal birth, is AWE-INSPIRING!! Thanks for reading!!

  4. atyourcervix Says:

    I wish we had a comprehensive anesthesia consent for women to read over and sign. Alas, we only have a general delivery consent for vag/section/all anesthesia. It barely touches the surface of a true informed consent.

    • nursingbirth Says:

      atyourcervix, I hear you! Our cesarean consent is just the blanket operating room consent, same as is used in the main operating room for ANY surgery. It is very vague and I agree, it barely touches the surface of informed consent!!

  5. Rose Says:

    in regards to this that you posted:
    “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.””

    I had a patient once, who had a primary c/section, as a primip,for failure to descend. she pushed 3 hours and the baby didnt come out. so she decided to have another c/section. already scheduled it. at her 38 week appt, her doc told her that her cervix was favorable and she’d be a good vbac candidate. so when pt went into labor that same week, and her doc was on call, she decided to go ahead and try the vbac. then, she said she thought the epidural was why she couldn’t push good enough thefirst timeand had a c/section. so she did this labor completely unmedicated, pushed 2 hrs and had her vbac. she cried and cried.

    but you’re right,not many consider the negative effects of the epidural. most anethesiologists mention “the biggest risk is a bad headache….”, and there is one who goes into detail about how it won’t always work as good as you expect (b/c you know someladies expect to be numb from chin to toes)…

    • nursingbirth Says:

      Rose, I heard “the biggest risk is a bad headache/it won’t work” all the time at work! I actually was watching the documentary “Orgasmic Birth” tonight and the anethesiologist they showed talking to a patient about her epidural even said “the biggest risk is a spinal headache…have you ever heard of that before?” And I have also met women who expect to be numb from “chin to toes” as you put it, haha! What a rude awakening especially since they aren’t numb but they still can’t move much without someone else’s help! THank you for sharing that experience you had with a patient of yours. I probably would have cried right along with her! Birth is SO POWERFUL!

  6. Amy Romano Says:

    Oh, I hope you know I didn’t think you were anti-epidural. In fact, I completely applaud you being willing to really talk about epidurals! Sometimes, our (both women’s and providers’) desire for the natural experience can turn into disdain for intervention. But if we don’t accept why epidurals are so appealing to women, then we won’t ever be able to talk about this stuff as it is mean to be talked about. It’s really refreshing to see a practicing nurse see it this way. I know there are actually thousands and thousands of nurses who want to fix what’s broken with our system. It’s brave of you to be one of the few who are so vocal – and it’s clear your message is resonating. Great work! 🙂

    • nursingbirth Says:

      Amy Romano, don’t be silly! I never thought you were implying that 🙂 I really appreciate all of your feedback and I really look forward to reading all the comments people post because I learn so much myself from writing this little-ole blog!!

  7. Laura Says:

    I was at a family gathering over the weekend. My sister-in-law is 31 weeks pregnant and she and her girlfriends/neighbors who were also at the party were discussing labor. One of them brought up another friend of theirs who wanted to do the unbelievably bizarre (to them) of laboring in a tub. I tentatively ventured that some women find it to be very soothing and help with the contractions. All I got in return were blank stares. I didn’t feel comfortable pursuing it further since these women were all about a decade older than me with multiple children while I’m still waiting for baby #1, so I figured I’d get a lot of “what do you know about it” responses (plus I don’t think a child’s birthday party is an appropriate place for a medicopolitical rant).

    From that one comment though I heard a lot of “but I couldn’t have my epidural if I was in the water”, “with my second baby things happened so fast that they just knocked me out and I woke up with a baby – couldn’t I do that again?”, and “no thanks, I just want my drugs and to be in bed.” I couldn’t believe how all of these experienced mothers were so unwilling to consider other alternatives and viewed anyone who did as weird. Based on their reactions, I doubt any of them have heard of the Cascade of Interventions or considered the potential effects of breaking the blood-brain barrier.

    I’ll never judge a woman for her choices during labor; I think it’s more important that a woman to be satisfied with her labor experience. Since I read a lot of birth activist blogs I guess I didn’t realize exactly how rare my views towards unnecessarily medicalized births still are.

    • nursingbirth Says:

      Laura, situations like the one you are describing are incredibly awkward, I hear ya girl! I think part of why many women are so unwilling to consider other alternatives is out of fear and it makes me so sad. I am so happy you have found the birth advocacy blog circuit! Thanks for reading!!

  8. […] was a fascinating post on Nursing Birth today about the giving and taking of informed consent for anesthesia (epidurals, etc.) for labor […]

  9. amelia Says:

    Thank you for this post! I just have to tell you that I LOVE your blog!

  10. Joy Says:

    And how does the law expect this signed consent to be legal in a court (should it come to that)? Doesn’t one have to be in their “right mind” to sign such things? I don’t know about other women but I am not in my right mind when I’m in labor!

    I had epidurals with both of my daughters. I am not sure yet what we’ll do but I’d like to try to labor and deliver without medication.

    • nursingbirth Says:

      Joy! I have got a new movie suggestion for your to watch: Orgasmic Birth! I just saw it for the first time yesterday and it was very well done 🙂 Don’t forget also that The Business of Being Born is a MUST SEE!

  11. Among many reasons why the desire for an unmedicated birth is cast in a negative light is the misconception that women are giving birth without drugs specifically to feel like an empowered hero, to feel better than other women, for the sublime (or orgasmic) experience or because someone on Mothering.com told them to. It must be a pathological character flaw to pass up pain medication, then. If a hospital offers it, it’s safe, right? So if you’re so crazy that you would want to be in pain, you must have a different angle of needing to feel better than others. Otherwise, you would shut up and appreciate what you’re being offered because your doctor says it’s perfectly safe.

    I have yet to talk to anyone personally who had an unmedicated birth for any other reason than anesthesia *could* negatively affect their baby, them, their labor progress and their chances for a vaginal delivery. I wonder why you’re not seeing these reasons being articulated to hospital staff either verbally or in a birth plan. Maybe because women assume it’s understood that that’s why they would prefer to give birth without an epidural? I know many women have epidurals encouraged by tired, overworked nurses with patient ratios that are too high and just kind of want them to be quiet and settle down. In this case, any concern about risks of anesthesia would be downplayed or denied.

    I believe that you’re right when you say that patients need to educate themselves in advance. I wonder if sometimes women latch onto the *idea* of a natural childbirth just… because. Not because they’ve educated themselves on the risks of epidurals and being stuck in a bed without freedom of movement, but just because they heard it was a good thing to do. Again, it’s about education. And expectations.

    • nursingbirth Says:

      Jill-Unnecesarean, You write:
      “Among many reasons why the desire for an unmedicated birth is cast in a negative light is the misconception that women are giving birth without drugs specifically to feel like an empowered hero, to feel better than other women, or because someone on Mothering.com told them to.”

      I too see this phenomenon and I’ve heard it like this: A woman is asked by her friend if she did or is going to have pain medication in labor. If she did or is planning on it she says “Oh OF COURSE! I’m not trying to be some kind of hero! The only reason women don’t take drugs is for bragging rights!” (P.S. I actually heard one of my coworkers say this to another coworker…..soo FRUSTRATING!!) This whole “just because the hospital offers its means its totally safe” mentality has GOT TO STOP! Women of the earth: TAKE BACK YOUR BIRTH! Haha!

      Also to somewhat answer your question, in my post I wrote about 5 “types” of responses. For the women who choose response #1, I often hear reasons of not wanting interventions to be very thorough, including “it could negatively affect me/my baby/my labor/my chances of a vaginal birth”. But for the women who answer #2, #3, & #4, I often do not hear these as reasons. I often hear the “ancedotal” reasons, including “so and so told me to do it/not to do it” or “I’m scared of needles”. And what do ya knoW! When women have these ridiculous reasons for not wanting pharmacological pain intervention, they are often swayed. Like the nurse will come in, convince them that the needle is “not so bad” and VOILA! They get an epidural because the only reason they had for not wanting one was something minor.

      Am I making any sense?! Haha! And I agree with you: “Again, it’s about education. And expectations.”

  12. bel Says:

    “A bad headache.” The anesthesiologist who gave me my epidural never even said such a thing. I wish they had – my “bad headache” lasted over a year and it was debilitating. Instead he just yelled at me that I wasn’t bending forward enough and then did the procedure anyway.

    I didn’t get the epidural for pain relief though. I actually avoided it all costs because I have a rare form of scoliosis and had a feeling the epidural would cause me problems.

    After other interventions (which I didn’t need, but trusted the doctors) left me still dilated at 4cm, and I had been in labor for 36 hours – 24 of those with pitocin and broken water, the doctors made me choose between epidural and c-section.

    I can’t wait to try this again my way — 27 weeks or so left!! I’m a bit concerned about my OB though. She doesn’t seem very comfortable with the natural birth philosophy. All the midwives in the area are booked. Wish me luck!

    Quick question — does hospital staff mind if someone has a very detailed birth plan with reasoning for some of the items? I don’t want to provide too much to read, but I wonder if the reasoning behind my decisions will give them more weight.

    • nursingbirth Says:

      bel, your story about debilitating side effects post-epidural are more common than people make them out to be. I am so sorry that that happened to you! No woman should feel “bullied” during her birth experience. It makes me so FRUSTRATED and UPSET that sometimes I just want to scream (and I have!) I love how you wrote, “I can’t wait to try this again my way” I LOVE THAT!! You go girl!! Take back your BIRTH!! About your question re: birth plan. PLEASE make it as detailed as you feel necessary. First off, anyone who is “annoyed” by your detailed birth plan would be “annoyed” by ANY birth plan. (There are nurses out there that have a control complex too) BUT IT IS YOUR BIRTH NOT THEIRS! I personally feel that even the “birth plan haters” at my hospital would really like to know about your last experience with an epidural and your scoliosis so i encourage you to be specific!! Also, I too am a bit concerned about your OB. Gettting a supportive birth attendant is the first step but if one is not available, please consider going into labor on your own (AVOID BOGUS INDUCTIONS AT ALL COST), consider hiring a doula (if it is within your budget), set up your “dream team of labor coaches” that SUPPORT your natural birth plan (so if mom thinks your crazy, consider only inviting her in AFTER the birth) and try to labor at home for as long as possible. WOW, i just wrote too much! Hope this helps!!

  13. Marissa Says:

    It’s not only in birth that truly informed consent is being skimped on. when my boyfriend was in the ER with a ruptured appendix he was just handed his consent form and told to sign with no discussion of risks at all, and wasn’t really even given a chance to read the form. I ended up being the one to do most of the explaining about what to expect from the surgery. the ER nurse even told him that “they don’t usually put in catheters”, I’m sorry, but I’m pretty sure anytime they do a two hour abdominal surgery, you can expect to be catheterized. they also gave him morphine without telling him anything other than it was a pain killer. I had another friend who’s an international student in the ER with abdominal pain a few weeks ago, and they really didn’t make sure he understood that they were giving him morphine or that it would make him feel funny.

  14. Christina Says:

    I totally agree with the quote re: personal education/personal responsibility. As a childbirth educator, I really stress informed decision making as well as offering more detailed risk/benefit information for common procedures & medications… But I also know that some of my families are planning to give birth in hospitals with care providers who might make self-advocacy very uncomfortable/challenging to the birthing mother/partner. Where what that family is trying to achieve is not the routine of that practice/hospital, and is really going to depend on luck – the chance of getting a supportive nurse or getting a specific doctor/midwife etc & etc. We discuss the importance of aligning choice of provider/birth place with their personal hopes for the birth, but I feel like most of my clients don’t believe just how hard it might be to go against the normal flow of things. I do have some who switch, but many don’t. Your “don’t let this happen to you” series is the perfect example – some of the stories really highlight the “behind the scenes” aspects of how decisions really get made, and just how hard self-advocacy can be in certain situations. Basically, while I think it’s incredibly important to educate ourselves, I also hope that things change so self-advocacy is more respected & encouraged.

  15. I occasionally give the birthing tours of my unit to pregnant couples. There are a lot of questions about pain management, which thankfully my institution uses a lot of alternative measures (whirlpools in every room, birthing balls, massage, hypnobirthing etc). One of the top questions is “When can I have my epidural?” I always recommend to all the pregnant couples, even if they are hell bent on an epidural (which is fine) to take a natural childbirth class. I do this so they can learn some alternative pain control measures, because even with an epidural, birth is not sensation free. Some women come in with the expectation of having an entirely sensation free delivery, and are so disappointed and angry if they get their epidural late, or they feel the “ring of fire” when crowning. I really believe that natural childbirth techniques help give the woman a sense of control over her own body. As far as the informed consent issue, this crosses all areas of hospital care. Women should be aware of what they are reading and signing, but are they? There has to be some patient responsibility in their own decision making.

  16. Rebecca Says:

    I once saw a woman rip the forms out of the anesthesiologist’s hands to sign them. She was Spanish-speaking and he had to do the consent through the translator phone, she had been in labor for probably 20 hours at that point, and he got maybe three sentences into the consent. The thing that was funny about it was that she was the nicest, sweetest, most mild-mannered person who I would never imagine doing anything like that, and she just snatched them away from him, scribbled her name down, and started to moan through another contraction. I think that says something about the need for explaining procedures before labor.

  17. Kathy Says:

    Love this discussion, and am going to reply to many of the comments (but will try to make it short)…

    RR — you can also remind them that there can be quite a bit of time between the request for an epidural and them actually getting numb (for instance, the anes. is attending a C-s), so they might want to at least have some NB tools, in those cases.

    Bel — you’ll need more than luck!!!! One of the biggest differences between women who end up with natural vs. interventive or vaginal vs. C-section births is their care provider’s attitude (as well as that of their nurses). GET A DOULA at the very least. Formulate your birth plan NOW and discuss it with your doctor from now until your birth — but be very aware that if she’s not receptive to your plans *now*, she likely won’t change except for the worse when you’re in labor. Talk to the nurses at your hospital and see if there are any of them that are more supportive of your plans, then request one of those nurses in labor. Finally, you may want to check again for midwives (it’s possible that one of their current clients has moved or will move out of her care for some reason), and see if you can go that route. Or choose a different doctor — don’t be boxed in by your insurance plan. You may end up paying more for an in-network interventionist birth than you would for an out-of-network natural birth. Besides, how much would you have given to have been able to avoid your year-long headache due to an epidural you wouldn’t have chosen had you had more options? Out-of-pocket costs aren’t the only consideration!

    Feedingtime — this actually doesn’t surprise me too much — the Pit w/o knowledge, and/or a blanket consent form. Although I had a home birth with my first, I got a “pre-admittance” form from the hospital where we would have transferred were it necessary, and it about made my mouth drop open. Basically, it sounded as if I signed away all my rights upon admittance. I forget the exact language, but it was something along the lines of “by signing the admitting form I authorize the hospital staff to do whatever they deem necessary.” Which makes me think that if your hospital was similar, then you may have authorized them to give you Pit w/o your express knowledge just because they decided it was good or necessary for you. And I was expected to have the form filled out and on file with the hospital before going into labor, so that would mean absolutely no informed consent — it was just “blanket consent for anything and everything.” Sorry, but as a thinking, reasoning adult, you actually *do* need to explain things to me — you’re not God, as much as you might wish you were. [Sorry for the mini-rant, but it irritates me every time I think of it! :-)]

  18. This is a great discussion. Thanks.
    For those of us who are childbirth educators, I think we need to look at desires of women and frame things in a way that meets their needs. Validate their desires.
    For those who want to reduce their pain – let labor begin on its own; have great, skilled support; avoid interventions (unless medically mandated) because all those interventions are sources of pain (IVs, not eating, rupturing your membranes; move and be upright (shorten the length of your labor!) and birth in a place with options like a tub, a birth ball, walking space.
    For those who want to be in control/involved in decision making – avoid an epidural as you loose your mobility and most of the decisions are then medically driven (the need for pitocin, catheter, monitoring, etc)
    For those who want a shorter labor – move, be upright, avoid the epidural.
    The reason I love the key practices that Lamaze promotes is that I truly believe the issue is not epidural vs no epidural. The medical management of birth has taken what is normally a challenging but do-able event like birth and even created MORE PAIN on top of the normal physiological pain. And if we work hard to remove the added pain sources (immobility, understaffed nurses who have limited time for hands on support, lack of doulas, routine interventions, few options to move and be upright, etc etc) then a woman’s need for pain relief will also be reduced.
    But as long as the model of birth adds PAIN then we are asking women to tolerate more pain then they would normally have to deal with. See what I mean? As a childbirth educator I have to make sure she is competent in meeting the normal pain of birth plus all the EXTRA pain. You can learn more about the key practices at the lamaze.org website.

    And for those women who don’t mind a more painful or longer labor or less involvement in decision making, there are easy to get options for them. It’s the women who don’t want that, that have to work hard for options.

    Thanks again for getting this discussion going!

  19. Kat Says:

    Melissa,
    I would LOVE to reprint this on my blog if that is ok. I attended a birth that ended in a c-section and I think the epidural was partly responsible (would love to email off-line about that as well!). Let me know!
    Kat

  20. Mama Kalila Says:

    I was one of the ones that knew the risks before-hand. I had planned a natural delivery… but I guess I fell in camp #2 lol. I really didn’t want one, but being my first kid and thinking I had to use a hospital (long story that you already have heard) I figured if I needed it I would and not feel bad about giving in… But because of that I did all the research, re-enforced my desire not to have one lol… in the end I gave into fear.

    That being said… I do not remember my consent form. At all. I don’t even remember signing it. I know I had to have… but it might as well not have happened.

    Feedingtimeatthezoo – That happened to me too. I specifically said no pitocin in my birth plan, went over that w/ everyone… and they told me they were putting in a saline solution. After giving birth I went to the restroom, looked up and saw pitocin written on the bag. I was ticked.

  21. […] above italicized portion was from Nursing Birth blog. Click here to read the rest of the very informative post, including an actual hospital informed consent form […]

  22. bel Says:

    NB and Kathy – Thank you so much!! Your suggestions (and support) are really helpful!

  23. Lynz Says:

    Thank you for posting this. I do love to read what you have to say, especially as I look into becoming a L&D nurse myself.

    I just delivered my fourth, and for the first time, I did it without an epidural. I was very proud of the fact that I was able to accomplish my goal, however, I do have to say that even with all the knowledge about epidurals (much I learned from the references you post, thank you!) I found that I enjoyed my deliveries with epidurals much more. I did very well this time, up to the point of transition, after 7cm I felt like my body was going to rip in two and I couldn’t even consintrate enough to keep my wits about me to push. Once I did start to push things went very quickly (10-15 minutes), as did my entire labor without the epidural. 4 ½ hours compared to the next shortest of 8 (but I’m not sure if that is partly because this is number 4). I did notice many other things as well, but I don’t have time to write them all.

    So, I do have to say, being much more educated this time (I felt I was with the previous 3, but you can never learn enough I guess), I think for my last, I will opt for an epidural, but a little later in labor (when we get around to number 5).

    Keep up the great posts!

    • nursingbirth Says:

      Lynz, I am so happy you got something out of all my jibber-jabber! 🙂 I am most excited and care most about the fact that you have had positive, empowering birth experiences much more than any old epidural 🙂 But I am so happy you felt like you accomplished your goal! I hope you feel like you can do ANYTHING! Congrats!

  24. khalilaann Says:

    Thank you so much for making this! I’m a FTM due in a few months and this is the best resource I have stumbled upon so far. In all of the books I have bought, internet sites I have searched for, and even the big spiral book the hospital gave me I haven’t gotten information as helpful as I found in the first couple of posts I read on your blog. And I have searched high and low for information on risks/benefits of medications offered during the birthing process only to find “this is when we do it and this is how we do it” information. So this post especially was very nice! 🙂 I feel like I’m rambling now, but I wrote more about it on my worpress if you feel like reading the rest of how you got my mind going. Thank you!

    • nursingbirth Says:

      khalilaann, thanks for your comment!! it really means a lot to me!! I am so happy you are finding my ramblings useful! I hope you visit again! Spread the word to all your friends!

  25. Mama Kalila Says:

    I just saw the last two messages and had to smile. 🙂

  26. kgjames Says:

    Late response, but I’m preparing my birth plan. Thought I’d share part of the “labor practices” paragraph:

    It is important to me to birth these babies naturally. I would like to avoid induction, AROM, epidural, and cesarean section. Since I had a low-horizontal cesarean section in 2004, medical inductions and augmentations are not appropriate – they significantly raise the risk of uterine rupture. Continuous fetal monitoring is considered the best method for detecting possible scar issues (i.e. rupture); I prefer external monitoring via telemetry. Please do not offer me pharmaceutical pain management drugs – the risks outweigh the benefits. Please discuss all labor interventions with me and my support team before proceeding.
    ~ Kimberly
    http://labortrials.wordpress.com

    • nursingbirth Says:

      kgjames, THANKS for sharing part of your birth plan! I LOVE the wording, it shows the practitioner that you are a) educated/informed/have done your research, b) empowered, and c) the “boss” of all of the decisions to be made regarding your care. No one could claim you just “copy pasted” off the internet! LOVE IT!

  27. […] is a really great post about Consent for Anesthesia at Nursing Birth’s blog.  It demonstrates why it is SO important to get educated about […]

  28. Saylor Says:

    Thanks for putting the copy of the consent for anesthesia out there. Honestly, I have no idea what I signed before my c-section!

    I’m thinking about getting pregnant soon (wanting a VBAC) and at my last OB/GYN appt, I told my doctor I knew I didn’t want an epidural next time because of how horrible the nausea and vomiting were (that’s not even including all the other risks!) after I recieved my epidural last time. He said that epidurals didn’t cause nausea and vomiting–that was just a side effect of labor. So glad you put this out there to prove I was correct–it says it right there on the consent form!

    My doctor is the only one in my area who will do a VBAC, but when I asked him about it, he made sure to tell me about the risks of uterine rupture. He said it happened in about 7% of VBAC. I feel like he was really trying to persuade me for an elective c-section. Since then, I’ve done the research and seen how inaccurate that statment about uterine rupture is…wish I could switch to a midwife, birth center, or anything else! Homebirth’s not looking so “out there” now!

    As someone who works in a hospital, you probably only see homebirths gone wrong, but what is your perspective on them? If I can’t get the birth I want in my hospital, I might be looking into other alternatives, but my husband would totally freak out if I told him I wanted a homebirth (with a midwife)…he’s so worried about something going wrong, but I’m going to make him read Born in the USA. That’s a great book!

    Thanks for writing the blog. I just found it today and I’m really enjoying the education!

  29. More people need to know things such as this.

  30. Molly Says:

    I had a drug-free birth, but was given Pitocin after birth without my consent. Actually, my birth plan SPECIFICALLY stated that I didn’t want pitocin following my baby’s birth. I knew that this particular hosptial routinely administered pit after birth and so I spoke to my doctor about it before hand and everything. And STILL got it. That’s what I get for allowing them to give me an IV in the first place.

    Since I was still on a high from birthing my perfect baby, it didn’t really bother me at the time, but now it really irks me.

    Thanks for this article. I’m going to link back to it at some point – so good!

  31. […] what does a consent form for an “elective primary cesarean section” look like? Since my post “Consent for Anesthesia: Do You Know What You Are Signing?” was such a big hit, I have decided to follow suit and post a copy of an actual hospital consent […]

  32. Renee Says:

    Our consent is a joke, we use the same paper for consent of EVERYTHING in the hospital, AND it has to be signed BEFORE anesthesia comes into the room! So they are signing BEFORE they have informed consent… the few times I tried to buck the system, I have been thoroughly reprimanded.

    I echo your feelings on this issue, and in my classes try to show the cascade of interventions in a way that gets the moms/dads thinking. Someday….

  33. kgjames Says:

    I found a cesarean consent form on the internet that looked workable. I altered it and plan on showing it to my OB at my next appointment. One of my big modifications was to expand it from an elective cesarean form. I have a line for consenting to EC, a line for withholding consent until an emergent situation would present, and a line for indicating who holds medical power of attorney in the event that I am unable to consent to surgery.

    Our hospital just hands out the general “invasive procedure” form for signing. The same one I signed when I had a hysterosalpinogram performed there. Insulting.

    ~ Kimberly
    http://labortrials.wordpress.com

  34. […] interventions and medications that may be used during labor and delivery.  Cervidil.  Pitocin.  Epidurals.  Narcotic pain relief.  Amniotomy.  Cesarean section. Episiotomy.  And many […]

  35. Well, having had 2 epidurals – one that helped me right into an unwanted and traumatic cesarean, and one that was about to help me have a second cesarean had I not wised up and had the stupid thing shut off – I can say I’m pretty unapologetically anti-epidural these days. But I know some women who think they were the cat’s meow. The problem is, I hardly know a single woman whose cesarean wasn’t caused by one, or whose VBAC wasn’t ruined by one. In fact, chances are, any time a hear a cesarean story, there’s an epidural in that “failed” labor somewhere. Never surprises me.

    I think there are better ways to cope, and yet no OB is telling women to take a Hypobirthing class when she’s sitting in a prenatal appointment asking if she get the epidural before she has her first contraction. Do they even want women to know that there are other ways? Doesn’t seem to me like they do. Until the risks of epidural become common knowledge, and the alternatives to them become more widely known, I’ll probably continue to be vocal about my distaste for them.

  36. Kayce Says:

    I just started reading your blog and I love it!!! I am planning on becoming a nurse so I can eventually be a CNM, so I really enjoy all things birth, including (especially) blogs. Because I plan on being a nurse, I was able to do an observation in L&D at my local hospital. I got to watch an epidural and two births while there. What shocked me while I was there was that the anesthesiologist didn’t even give the mother the “informed” consent to sign until AFTER the procedure!!! He said it was because he wanted to make her comfortable so she wasn’t signing things while in pain. I was flabbergasted! I can’t believe the things that actually go on these days. I truly hope you will be able to make the changes you are striving for. I will be on my way to helping with that cause as soon as I can. 🙂


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