21 April 2008

Epidurals: get one even before pain starts

I know it was only recently that I wrote about epidurals and the post generated quite a large response...Nevertheless, epidurals are back in the news as a result of a new book Enjoy your labor: A new approach to pain relief for childbirth, by Dr Gilbert Grant, director of obstetric anaesthesia at New York University Medical Center. Grant argues that the old adage of 'natural' is best when it comes to birth is no longer applicable. In fact, Grant suggests that women should have an epidural even before they experience any pain associated with birth.

Whilst I agree, as Grant contends, that there is relentless pressure on women to give birth 'naturally' and that many women feel guilty when they choose to manage pain with epidural, the fact is that Grant suggests the opposition or at least the feminist critique of pain management methods in misogynist. He says:

"Childbirth instructors describe epidurals as unnecessary, or even harmful, interventions and make women feel that requesting one is a sign of weakness that may harm their baby. Labour is seen as an extreme sport - ‘no pain, no gain' - and yet this quasi-religious fervour is based on myth and misconception."

Hmm. While there are contingents of 'natural' birth advocates who argue that all pain medication in birth is 'unnatural' and 'bad', the majority of feminist critiques surrounding the use of epidurals is not that women are 'bad' mothers if they choose to use them. Feminists argue that it is the way in which epidural is presented as the default option for pain management in a highly medicalised environment that is problematic. Grants continues:

"It is barbaric that pain should still be viewed as an integral, even desirable, element of childbirth.”

In fact, I don't think the work of any feminist scholar of childbirth suggests that women 'should be in pain' in order to have a 'real' or 'authentic' experience of birth. Whilst this might be part of cultural narratives or even imperatives surrounding how women should 'do' birth correctly, this is a much different angle from scholarly work in this area.

Even more alarming is this suggestion:

"Technological advances mean that women are able to administer their own dosage and this makes them feel more in control. Furthermore, studies show that babies born to women who have had epidurals come out in better shape than those from ‘natural' childbirth."

What really bothers me about this statement is the association between control and technology. Women clearly can be empowered with medical advances in pain management as well as with other forms of reproductive technology. However, Grant fails to recognise that 'empowerment' rests on choice and in many American hospitals, for instance, the notion of 'choice' becomes blurry when women become part of a cascade of interventions which limit her ability to make decisions on her own. For instance, the reason so many women in America use epidurals is not just because they want them; with the induction rate close to 90% in some New York hospitals, for instance, epidurals become essential because contractions are so intense without a gradual build up. In these case, an epidural becomes routinised as a necessary medical intervention when perhaps many of those same women might not have chosen an epidural had they been able to allow labour to progress 'naturally'.

Nevertheless, I think it is a very dangerous proposition to suggest that epidurals should be part and parcel of birth without the inclusion of their risks. Moreover, this whole 'epidural before pain' framework only entrenches the notion that birth is scary and painful. Again, of course for some women it is intensely painful and everyone should acknowledge that, but the idea that women should be pre-medicating in anticipation is just ridiculous. Why not encourage women to learn alternative ways to manage pain before resorting to chemicals?

Moreover, the idea that pain must be pre-managed also suggests that women can never have 'positive' experiences with intense pain. If the pain of birth was so horrible, women would never have babies. Many women tell me that whilst birth itself was one of the most challenging moments of their entire lives, they felt like they had accomplished something; not because they had endured alot of pain and survived. They felt accomplished because birth is an intensely visceral experience and for some women, feeling childbirth in every ounce of their being is something they would not want to give up with medical intervention.

In the Netherlands, women are not allowed to have epidurals unless the mother is in a high-risk category. Whilst, I do not necessarily agree with this more extreme measure, the truth is that the majority of Dutch women give birth at home with a midwife and the maternal and infant mortality rate is extremely low. Why is it that in rich, 'Western' countries maternal and infant mortality rates are still relatively high? The answer lies in the unnecessary invocation of medical interventions (and not only epidural).

What do you think?

Source: http://women.timesonline.co.uk/tol/life_and_style/women/families/article3625980.ece


Cherryskin said...

"the idea that pain must be pre-managed also suggests that women can never have 'positive' experiences with intense pain"

This is a concept that is very seldom discussed, I have found. I am lucky enough to have a wonderful friend who knows other wonderful women, and she passed onto me the idea that it's possible to ENJOY the pain of contractions. Sounds bizarre just saying it, but it's true! When I was in labour with my second child, I used those words of hers and they worked. As I felt the contractions coming on and intensifying, I concentrated on *enjoying* them -- without sounding hippy, I actually embraced the pain and rode with it. It was hard but exhilirating at the same time, and when I felt like I couldn't do it anymore and asked for pethidine, the midwife checked my dilation, and told me my baby's head was right there, and it was time to push! Then my focus went immediately off the pain and onto pushing out my baby, as it did in my first labour. (Thanks for contributing to a great labour, dear Bekka.)

Anonymous said...

Gilbert Grant was my anesthetist when my son was born. He is a God. His book is a Godsend. While simplistic (and I can understand that considering he's pitching at women who have been fooled by the midwife lobby forever) he is absolutey right.

The midwife lobby has now realized they dealt badly with the availability of epidurals and will be out of business if women realize that they CAN have a safe painless delivery. Because no sane woman would choose pain if there was a safe alternative. So now they've started a 2 prong attack which Grant deals with:1. they puff up the risks to make them seem scary 2. they introduce moral claims about pain being a positive experience not just a side effect.

Bollocks. Pain is NEVER a positive experience. It NEVER contributes to a positive experience (though I agree you can have a positive experience IN SPITE of pain).

To cherryskin - if you can enjoy contractions you're a nutjob or you haven't suffered enough. To any woman I know labor pain is the worst pain they ever experienced in their life and once in the vicelike grip of labor there is nothing they wouldn't do to make it stop. No doubt for some freaks its just like a bad period. But most women find labor bloody excruciating thanks very much.

Anonymous said...

Oh and I asked for my epidural before the pain started (I was admitted after my water broke and had no pain for hours). The nurses dragged their feet and argued despite my having seen Dr Grant beforehand to authorize early epidural. Because I have a condition that requires antibiotics before any spinal or epidural or other invasive procedure I had to then wait through 3 hours of agony before the epidural (took 1 hour to get the IV then 2 hours to receive the fluids). The worst 3 hours of my life. Totally unnecessary torture inflicted on me by a system that believes the nonsense spouted against Dr Grant.

The fear that an Australian hospital will be even more backward when it comes to early epidurals is one factor making me not want to have another child. So much for forgetting labour pain - I will never forget what was forced on me by the midwives.

Anonymous said...

How disappointing that you judgmental women out there can't stand it that we epidural-lovers have nice painless, calm births.

I like the following from a blog on fit pregnancy - by a labor nurse no less:

"What do I think of un-medicated childbirth? I think it hurts. Quite a lot actually. Sure, there are some that say it's the fear, lack of knowledge and tension that causes the pain. I say it's an eight-pound baby being squeezed at two-minute intervals for a whole lotta hours out our "butt" that causes the pain. But then, that's just me. I've done it myself both ways—with and without epidurals. I'd get an epidural again in a heartbeat. I've also attended thousands of births—both ways. Far more women choose some form of pain management (either narcotics or epidural) than go au' naturale. Why? Because most women think labor hurts and there's a good way to make the pain stop right at their disposal."

Right on. I once heard the proportions were like pulling a lamb roast out through your nostril. Sounds like what it felt like to me. If I had had a nurse who would get off her butt and organize the epidural in time I'd have had one in a second. Instead I can barely remember my daughter's birth because I was deleriously in pain. I wanted to die. What a nice way to condemn women to give birth that is!

My touchstone question is - what would a woman in the year 200BC on the east African plains have said if you'd asked her if she wanted something with miniscule risks to give her a painless labor? If she would jump at it then it's natural. An epidural IS the natural choice. It is unmedicated delivery which is unnatural.

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