What to Say to a Woman with an Epidural (Besides the Dentist Analogy)

Epidural

What to Say to a Woman with an Epidural (Besides the Dentist Analogy)

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You wouldn’t go to the dentist to get a tooth pulled without using any Novocaine!  It’s the same thing during labor.  Who would want to do it without the drugs?!

I’ve heard lots and lots of people use this analogy over the years: women, men, mothers, pregnant women, nurses, doctors, etc.  And every time I’ve heard it (or a version of it) uttered, it makes me cringe a little.

To clarify, this is not because I’m “anti-epidural.”

Yes, I do think that women should be given/seek out information about the risks and benefits of epidurals well in advance of their labors (and not when they’re in the midst of a contraction and the anesthesiologist is handing them a consent form and OMG, THEY’LL SIGN ANYTHING, JUST PLEASE START THE EPIDURAL NOW!!!).

And yes, I’ve given birth without an epidural.

But this is different–much different–from being “anti-epidural.”

Because you know what?  During that 14 hour unmedicated laborYou’re darn straight there were moments when I considered getting pain medicationI understand the desire to get one.  Completely.

And you know what else?  I’ve seen births where I believe, in my doula’s heart of hearts, that an epidural made the difference between a vaginal birth and a cesarean section.  That’s right.  For when used with discretion, in the right circumstances, in cases where women are well-informed, and when it is wholly a woman’s choice to request pain medication, epidurals can be wonderful, wonderful labor tools.

Now that my stance on epidurals is (somewhat) clear, I want to get back to that “dentist analogy”: that giving birth without drugs is somehow comparable to getting a tooth pulled without drugs.

Please bear with me while I briefly put on my philosopher hat: in terms of argumentation, analogies are evaluated in terms of their relative strength or weakness.  The more that the two components of an analogy have in common, the stronger the analogy is.  The less they have in common, the weaker it is.

So.  It should go without saying that giving birth and getting a tooth pulled have essentially only one thing in common, and that is that they both involve a certain amount of pain or intensity in the human body.  But this is pretty much all that they have in common.

For the pain of labor is (for the most part) non-pathological, while the pain of getting a tooth pulled is pathological.  Uterine contractions are a function of a normal body process, and initiate (unless a woman’s labor is induced) endogenously; extracting a tooth from a person’s mouth is not part of a normal body process, and the pain initiates from a source outside of the body.  What’s more, there are many non-pharmacological comfort measures (such as birth balls, massage, position changes, heat and cold, hypnosis, hydrotherapy, etc.) available to women during labor.  There aren’t many similar tools available to people getting their teeth pulled.  (There isn’t even enough room in your mouth to bite on that proverbial bullet!)

In addition, I think that the dentist analogy belittles the reasons that a woman may appeal to when opting for a drug-free birth.

For unless someone might have to forgo Novocaine during a dental procedure because of some conflicting health condition (and you have my deepest condolences), most people could find no reason whatsover to say, “Hey, Dr. Dentist, I’m good without that shot of anesthetic.  Why don’t you just go ahead and drill away, pain-med free!!!”

But there are reasons that women might choose (or at least hope to) forgo an epidural during labor.  (And NO!  It’s not for that damn medal!)

Some women might find compelling the preliminary research regarding epidurals and their effects on breastfeeding.

Still others might want to avoid other well-researched effects associated with epidurals, such as an increase in instrumental delivery, a longer pushing stage, greater need for contraction stimulation through synthetic oxytocin, and a higher incidence of very low blood pressure and fever in the mother.

And few, if any, people who plan on avoiding pain medication during labor make these plans with the hope of being a martyr for the pain.  They have reasons–reasons that are a far cry from the ridiculous notion that it would be “cool” to try out something similar to having a small power tool drilling into their teeth or gums without any anesthetic whatsoever.  (Okay, now I’m really cringing!)

But more than this, from my “doula perspective” I don’t think that the dentist analogy offers the sort of reassurance that a woman wants or needs when she gets an epidural.

To be clear, reassurance probably isn’t necessary for a person who has decided well in advance that she definitely wants pain medication during labor.  If she made a well-informed decision that was right for her and then followed through on that decision, then good for her!

But for people who were undecided, or who were very committed to going without pain medication, reassurance might be just what they need to move forward in their labor with confidence, empowerment, and peace within themselves.

And I’m not so sure that the “dentist analogy” achieves this goal.

In fact, I think that it does anything but achieve this goal.

So when a client or a friend of mine is feeling unsure of or disappointed with their decision to receive pain medication after they’ve already received it, here’s what I like to say instead:

  • An epidural is one of the many tools that are available to you during labor.  You’re just making use of one of your tools right now.
  • Getting an epidural does not mean that you are weak: it takes a lot of strength to make such a major decision in the middle of labor.
  • It takes courage to change course during labor and choose something that you weren’t planning on choosing.  You came well-prepared, and one thing you brought with you was flexibility.  That’s great.
  • I can still help you change positions, and I will stay here with you while you rest.  I’m still your doula even when you have an epidural!
  • You made the decision that’s right for you–that’s what matters.
  • I think you made a good decision.

See?  There’s no need for a bad analogy at all.

***

If you’ve supported a woman during labor and she decides to get an epidural, what words of comfort have you offered to her if she seemed unsure of or disappointed with her decision after the epidural was in place?
If you’ve had an epidural during labor and felt unsure of or disappointed with your decision, what words of comfort or reassurance helped you the most?

image credit athenius22 on flickr.



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24 Comments

  1. Amber
    Amber11-14-2011

    Somewhat ironically, perhaps, it was my experience with dentistry that helped me decide to avoid an epidural. While I wouldn’t have a tooth pulled – or even get a small filling – without freezing, it’s not without its consequences and side effects. I don’t enjoy having my mouth frozen, so I thought that if I could get through birth without having my lower body frozen, I would prefer that.

    Yes, there were moments when I wanted the pain meds, but in retrospect I’m glad I didn’t have them. And, anyway, I had short labours so there likely wouldn’t really have been time.

    That was a slight digression, but what I’m getting at in a roundabout way is that every woman needs to make her own decision. And comparing apples to oranges definitely isn’t helpful, either when making that decision, or evaluating it after the fact.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas11-15-2011

      That’s a good point, Amber. I too felt very out of control even when it was “only” my mouth being frozen, and I remember NOT liking my relative “paralysis” after my cesarean section. I think this sensation can be a little disconcerting even for women who really love their epidurals.

      With that being said, if it came down to a point where my midwives thought that a transfer to the hospital was necessary, and if the recommendation for an epidural came up (for sleep, etc.), I can only be open to that possibility and to that recommendation. And if someone used the dentist analogy on me afterward, so help them! :)

  2. Renee
    Renee11-14-2011

    Great post Kristen! Thanks. I hate that analogy too. Although I would say there are two things in common – there is the pain you’ve mentioned, and that there is something being removed from your body. I think that is what some people are getting at. But someone else ripping out a tooth is WAY different than me (mind and body) and my baby working together to get that kiddo Earthside.

    I did have a med-free birth with my first, and I’m planning to with my 2nd. I did not choose this route because I wanted that damn medal. But I did do all that hard work, so I was wondering if you know where I could pick up my medal? Who actually gives it out? I don’t think I’d be so pompous as to put it on my mantel or anything, but I’d hide it in a drawer or something. Or maybe have it with me at my next birth to remind me I made it the first time. Seriously, I keep hearing about this damn medal. Where do I get mine?!?!?

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas11-15-2011

      That’s a good point, Renee. Although maybe the difference is still that babies born vaginally are typically not “removed” (unlike a tooth…unless the tooth is loose when you’re a kid, and then it doesn’t hurt THAT much…but I digress). But babies born via forceps, vacuum, or cesarean section ARE removed, and in these cases (especially with a cesarean section) pain relief can be a godsend.

      And did you know that Enjoy Birth does have a medal? It’s for all moms, and it’s awesome. :)

  3. TheFeministBreeder
    TheFeministBreeder11-15-2011

    I’ve talked before about how I used to use that novocaine analogy. I SOOOOO did not understand why anyone wouldn’t want pain-relief. Then I got that pain-relief, and alllll the bad side effects. Then I had a glorious, med-free homebirth, and man, what a world of difference.

    But I digress…

    AS A DOULA, I can tell you that I have worked much harder (and longer, so, so much longer) for my epidural moms than I have for my natural birth moms. In all of my epidural births (my own included) the epidural never worked as complete pain relief, and some women (myself included) ended up bed-ridden, in WRITHING pain. I’ve only seen one mom be able to sleep on an epidural. I’ve seen the epidural cause labor to slow, so I busted my butt making sure that we were changing positions and doing everything in our power NOT to let the epidural derail labor. Every one of those births has been over 24 hours long, and I’ve stayed awake all night long massaging backs, and applying heat compresses, and calming anxiety attacks. All on the epidural. I dare say doulas are more useful for epidural births than anyone can even imagine. I have never witnessed the epidural being the wonder drug that it’s supposed to be.

    Also, in my >10 births, here are some observations:

    The moms who said in their prenatal appointments that they absolutely wanted a natural birth ALL got their natural birth. Every single one, except the breech that required a cesarean (can’t find any providers around these parts to attend vaginal breech.)

    That’s NOT to say that they may not have asked for it at some point, we had just prepared for how to handle that prior to labor, and dug deep down to find extra coping skills instead of calling anesthesia. The extra coping skills worked like a charm. (That’s not to say they always will, but certainly coping skills go much farther than we’re led to believe.)

    The moms who said they’d “try” for a natural birth and see how it goes got the epidural. They just were not committed to natural, and (having been in that exact situation) I could tell that it was because the self-doubt and a lack of internal resources caused them to stop trying to cope earlier than the moms who were committed to a natural birth. I absolutely supported that decision in the labor process. If you can’t find the tools to cope, an epidural is the best option. I couldn’t find the tools to cope with my second labor, and I couldn’t imagine doing it (under those conditions) without the epidural. I hated getting it, but I really had no other options because I did NOT know how to get myself through that, nor did I even know how to let my doula help me.

    And if a mom ever feels guilty for getting her epidural, I just tell her she’s made the very best decision she could for herself. No judgment from me.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas11-15-2011

      I totally agree with you that doula work can increase when a mom gets an epidural. And that part about incomplete pain relief is something that I forgot to include in this post–THAT can be enough to make a woman say, “to hell with the epidural next time!” From what I’ve heard, it’s almost as if the pain gets WORSE when you expect complete pain relief, and then it’s not there.

    • Jen
      Jen11-16-2011

      Gina, I love this response! It took 2 births of saying I’d “try” for a natural birth and 2 c/s later before I got it. As soon as I said “I will” have a natural birth, it happened. And it was amazing, not that all 3 labors were really all that different, I just expected the 3rd to be hellacious and I prepared for it – I resourced myself. That is so key. And those “tries”? Right again, it was about lack of confidence and self-doubt, not about my capacity to manage pain, or I should say, intensity.

  4. TheFeministBreeder
    TheFeministBreeder11-15-2011

    Yep! That’s certainly what made me say “to hell with it.” I had a bad experience the first time, but hoped that the second would be better. Shame on me! It totally wasn’t, and I had to shut the epidural off to finally finish my VBAC labor (or risk that cesarean that I did NOT want.) Honestly, though, I’m glad I had those bad experiences with it. It made me seek out my homebirth, and I wouldn’t trade my homebirth for anything in the world! :)

  5. Andy
    Andy11-15-2011

    Kristen, I love your blog…and I mostly love this post. But…

    I noted with interest your link to the scientific evidence regarding epidurals and breastfeeding…I went there and was terrified.

    Not at the supposed link between epidurals and “problems” with breastfeeding, but by the wanton highjacking of the scientific literature. I know a little bit about epidemiology, certainly enough to know that a randomized prospective clinical trial is the highest level of evidence we have. PRCTs are the best way we currently know how to take out biases and confounders. So why would an article reviewing the “scientific evidence” discount the PRCTs in favour of retrospective studies (which are horribly affected by bias unless a very strong regression analysis is done) or even worse, speculation based on biological plausibility?

    I can only conclude that this review is, in itself, biased.

    I hope everyone involved with women and birth will learn enough about epidemiology and care enough to evaluate the literature themselves and how each of these studies should or should not inform their practice. Relying on the summeries of others, especially when they might be political, does women, and society, a disservice.

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas11-15-2011

      I understand where you’re coming from, Andy. And thank you for sharing your perspective. I linked to the S&S article because I think that it is more accessible than the Cochrane review of epidurals vs. non-epidurals and non-analgesia (which I have linked to twice here). And I do see how that writing/linking choice in and of itself could be criticized.

      I guess I’m wondering where in Henci Goer’s article you think that she blatantly discounts PCRTs? Or are you referring to the breastfeeding article? (And in this case, your criticism is DEFINITELY well-taken.) If it’s the latter, then this is why I didn’t characterize this reason in terms of “well-researched evidence” (like the Cochrane Review) and instead referred to it as “preliminary research.” From what I can tell, there *isn’t* enough high-quality research on epidurals and their effect on breastfeeding. Nonetheless, I also think that it is helpful for women to know what sorts of analyses are “out there” in order to try and make decisions in the absence of good research.

      Admittedly, does linking to this particular article demonstrate some bias on my part? Perhaps. But it’s more of a bias in favor of Science and Sensibility than a bias against epidurals (which, again, is something that’s well up for critique).

  6. Susan
    Susan11-15-2011

    I love this article. I am someone who fully intended an intervention-free birth (twice), and who had a doula to help both times. I did not have much choice in care providers when I had my first baby, and had a (possibly unnecessary) c-section after 16 hours of unmedicated labor. My second birth was a VBAC and I believed I was ready for a natural birth, but after a couple of days of start-and-stop labor I was too exhausted to continue and chose the epidural (and eventually pitocin, which I believe saved me from another c-section). I was so, so fortunate that it gave me complete pain relief and I slept for twelve hours before waking up to push for the next two hours as the epidural wore off! But at the moment I chose the epidural, I sobbed and sobbed and was afraid that people would judge me. Yet I still knew this was something I needed. I really needed that reassurance from my doula that she WAS NOT judging me and that I had made the right choice.

    I STILL believe that natural birth is the healthiest and best option for mother and baby when it is possible, but that sometimes other tools can help a mother achieve HER best outcome. Thank you for your flexible and practical approach, which I sometimes find lacking in the natural birth community. I bet you are a wonderful doula.

  7. Tracy
    Tracy11-15-2011

    I was 100 % committed to a natural birth – from the time I found out I was pregnant, until I hit 42 weeks.
    I was 100 % committed to a natural birth from the time the Cervidil was inserted at 8 a.m. on Friday.
    I was 100 % committed to a natural birth from the time my contractions began at 5 p.m. that same Friday.
    I was 100 % committed to a natural birth all the way up until 1 p.m. Saturday, when the contractions had me doubled over (as much as you can be when you’re that pregnant) while my husband helped me in the shower.
    It wasn’t until 2 p.m. that I asked for the epidural – 19 hours after my contractions began. I’ve been told contractions during an induced birth are 100 times more painful than regular birth. My son was born vaginally, after 40 minutes of pushing, at 5:59 p.m.
    While I was handed a button to increase the amount of drugs going into my body, I didn’t use it. I still felt contractions for four hours, but they were manageable.
    The epidural had worn off enough by 8 p.m. I could get up and go to the bathroom without assistance.
    I knew the pros and cons of epidurals before I went in. I’m almost positive if I wouldn’t have had to be induced, I wouldn’t have had an epidural. I’m positive getting the epidural was the right thing to do – this time.
    I have every intention of trying for a natural birth next time – but I know now, it’s not always possible.

  8. Rebecca
    Rebecca11-15-2011

    When I was in labor with my first, my really good friend Bekah was my doula. The father was in Iraq, and who knew if he’d get R&R at the same time? Anyway, I was having contractions for 3 days, until the last day when they got more intense. I wanted a pain-relief birth because in my experience, I figured why would I want a big needle in my back, when my body already produces pain relief hormones. My monthly cramps are nearly as bad as labor itself, I gave myself an episiotomy on a bike seat without an epidural, the only thing I’m missing is the actual pushing part.

    I don’t understand why I’d want a synthetic hormone to replace what my body already produces, because well, natural is stronger than all the synthetics in the world. It’s just me though. Also, the effects of the epidural on my baby weren’t there, she wasn’t groggy in the least. Whatever drugs the mother takes when pregnant, the baby gets too.

    I was asked if I wanted an epidural, I was uncertain, so all the plebotomists did was take my blood for the lab to process, and leave the consent form on a counter. My doula asked if they could come back later to see if I was ready for it. Turns out, I didn’t need it.

  9. Evelyn
    Evelyn11-15-2011

    when I was pregnant with my first child, I was the mom who did my research, but said in the end, “ill try to do it without drugs.” when labor started, I had horrible, super intense back labor. I went FAST – I signed the paperwork for an epidural, but before they could get the anestgesiologist in to see me, I was at a 10 and pushing. it was fast and intense, and I remember thinking that I would NEVER want another baby. just under 2 years later, I went into labor with my second. I went into it knowing that I could ep it without drugs bc is done it before. I also prepared for back labor, just in case, and I’m glad I did. my labor was nearly 3 times LONGER the second time around, so I’m sure if I hadn’t made up my mind ahead of time, I would have faced and gotten the epidural. I had an awesome nurse and 2 friends acting as my doulas while my husband was deployed. after that slower, less intense birth – still with back labor – I felt amazing. I felt like I could do anything. I was up and walking around within minutes after my son was born. my ob and the new nurse able just come on shift couldn’t believe it, they’d never seen anything like it. the nurse had NEVER seen a drug-free north, and my ob had only seen a couple. I’m currently 9 weeks pregnant with baby #3, and I’m planning my 3rd unmedicated birth early next summer. I’m hoping to have an “accidental” waterbirth (the hospitals here don’t allow it, but our insurance requires me to give north in the hospital since we can’t afford to pay out of pocket).

  10. Bree
    Bree11-15-2011

    As a doula, I also know very well the benefits of epidurals in certain births, the births where the difference between a c-section and a vaginal birth is made due to that epidural. But I also cringe when mothers are routinely offered pain medication in the middle of labor. In my state, L&D nurse are LEGALLY required to offer pain medication, which completely throws any birth plan request not to offer pain meds! I’ve had some great nurses who compromise by telling me (the doula) the options and trusting I will pass them, but many are not like that at all and worse, act like the epidural is completely routine, “this is just what we do now” sort of way. I’m sure all doulas have been to births where the epidural turns pushing from what may have been an hour or so to 3+ hours because they don’t have the freedom of movement.

    Sorry, feel like I’m rambling, but great post!

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas11-15-2011

      Oh, that annoys me too, Bree! Mostly because I think a lot of women hear, “You’re doing it wrong! You’re not coping well!” when a nurse (or anyone else) independently offers pain meds–even if she does it with the best and warmest intentions. (Or because s/he’s required to–ugh.)

      I guess maybe there are some women who don’t know what their pain med options are (??). But I try and remind clients to let the nursing staff know right when they arrive that they know their pain med options and will inform THEM if they would like any medication. That way, the choice is always up to the woman (as it should be).

  11. Leigh
    Leigh11-15-2011

    Going into my first birth a did a stack of reading as tall as me and came to the highly informed conclusion that an epidural would be a good option if I was not “OK”. That was my line in the sand. 10 days post due I was induced and as the pitocen dose was upped Tracy is right the contractions were like being smacked into a brick wall. I got close to not being OK and had the anesthesiologist in for the consult but was not ready to sign the forms since I was still not across that line (which they did not understand, but did not push it particularly with my Doula there.). Luckly my son was also not a fan of the pitocen and they dialed it way back. Labour kept going, I got a shot of nubane (thank you research into all my options) for a short sort of break and 14 hours after it all started I pushed his giant 9 lb head out. If the contractions had not changed I would have had the epidural, been annoyed with the effects of it (I really wanted to be able to move) but would have had no issues with choosing it.
    I agree that for some labours, an epidural makes a vaginal birth possible, and since everyone experiences labour and pain differently, only mama can decide when it is time. I found the not OK metric to be the most useful to me. I could not picture what labour would be like ahead of time, by I know myself and when I am OK to keep going or something needs to change. It also put me in a mindset of flexibility since babies like to make it clear from the start that mamas plans are just ideas.

  12. Cameron
    Cameron11-15-2011

    When people use this argumentI personally love to use an acronym that I stumbled across while studying to be a childbirth educator: labor pain is not like other pain, it ‘s P.A.I.N. – Purposeful, Anticipated, Intermittent, and Normal. I also bring up that there are entire societies on earth where women do not report experiencing pain during labor, which reflects the fact that expectations, socialization, and environment shape how women experience childbirth.

    …And all that said, epidurals can still be a great tool for some women! (:

  13. Ashley // Our Little Apartment
    Ashley // Our Little Apartment11-15-2011

    Just wanted to let you know that I absolutely love every word of this article.

    THANK YOU! :)

  14. Katie
    Katie11-15-2011

    One of my two vaginal deliveries involved a walking epidural, and the more recent one no epidural at all (although like you, there were moments where I wanted one but was aided by my team in regaining composure).

    My pet peeve is when a soon-to-be FTM is told, “Just get the epidural!” It grates on my nerves, because the person saying it has no idea what values and preferences that pregnant woman has, how her labor will go, or her comfort level when it comes to risks vs. benefits of the epidural. And sometimes men are the ones saying it, which bugs me maybe 25% more even though I know it’s because they don’t like seeing someone in pain.

    Basically, I don’t think epidurals are all good OR all bad. Because there are some risks to getting one (slowing labor, introducing IV fluids and catheter, infection, etc.), it’s slightly safer not to get one, but there are times in which the only way that particular woman is going to manage that particular labor in the way she wants and needs is to have an epidural. So basically, I try not to advise another woman in either direction, but to mention that I’ve done it with and without and that she could as well.

  15. Sheridan
    Sheridan11-15-2011

    Great points. I actually made a video about this topic. http://www.youtube.com/watch?v=I0xyB-Ujy8s Where I talk about dental work compared to birth and how there really is no comparison.

  16. thebirthmuse
    thebirthmuse11-15-2011

    I really love this post and your comments to the commenters. We are on the same page! I love the list of alternative things to say to a woman who has gotten an epidural. She will, possibly, beat herself up about her choice later, but the truth is that even she, from a future perspective, cannot remember what it was like to be in her shoes AT THAT MOMENT. So I believe we have to support women in all their choices. We have to be empathetic and loving and non-judgmental. At the same time, I will work (and work hard) to remove the environmental influences on all women’s choices in our culture. For instance, it’s not fair to offer pain medication to a woman in pain who has specifically said she does not want to be offered pain medication! And our media representations of birth (movies, TV, reality shows, etc) are awful. I am reading a book right now called “Thinking, Fast and Slow” that explains how seeing images (like medicated birth) over and over again really DOES have an impact on what we do and expect. We have a lot of work to do!

  17. ajira
    ajira11-17-2011

    Grr. The dentist analogy. Drives me nuts. I just don’t get it. I also don’t get why people feel the need to tell pregnant women stories about the most horrific births they’ve heard about. Not exactly inspiring. And you know what? Each of us does the best we can with what we have.

  18. nsv
    nsv11-18-2011

    I’m a little late to this party, but I love that you’ve tackled the dreaded dentist analogy. I’m someone who finds dental care terrifying and terribly painful, and would much rather give birth, which I find moderately painful, and completely joyous and powerful. (Unfortunately, by that reasoning I’d have more children than fillings, a scary prospect.) I suppose the lesson is that YMMV.

    I think what’s called for is a better analogy. When I’m talking with women about epidurals, I like to compare birth to a marathon. Why don’t runners routinely get the epidural before starting the marathon? They know it’s going to hurt, and think of the pain they might avoid. The point is that getting the epidural changes what happens – you can’t run as well, presumably, and the race might have a different ending. Doesn’t mean you can’t do it, of course, but it pays to really think about what you want to accomplish and what trade-offs are right for you, rather than just assuming the pain will keep you from accomplishing the goal you’ve trained so hard to reach.

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