It's Not Your Mother's Epidural
As separate and distinct as the two specialties of Anesthesiology and Obstetrics were during the 1970s and before, they are blended so intimately today that the subspecialty of “obstetrical anesthesia”–although not officially recognized–is practiced as if it were. Good news for today’s moms, especially when one considers the pain relief options available in the past.
Pain Relief in the (Not So) Good Old Days
Years ago, before each specialty had taken into account the physiology of the other in enhancing the total approach, there were some unpleasant glitches in obstetrical pain relief. For instance, the epidural anesthetic (in which numbing agents are squirted by a needle around the tissues of the spine for absorption leading to relief) was often hampered by erratic absorption, which led to difficulties controlling the timing and thoroughness of a patient’s pain relief. Some patients were “walloped” with numbing effects so extreme that they felt dead from the chest down, while others received spotty or delayed relief. The other choices—the older choices—included:
- Spinal anesthetic. This was a better guarantee of pain relief than the epidural in that one didn’t have to rely on medicine seeping around the nerves from the epidural space, but instead the medicine bathed the nerves directly. Unfortunately, the very hole in the covering over the spinal area could cause headaches later (treatable, but a nuisance), and the “wallop” was occasionally so intense it even affected breathing. Although this complication was addressed well, for a hospital was sensitive to this event and ready to act, still it wasn’t the stuff of pleasant memories.
- Narcotics. Given by IV, narcotics acted centrally on the brain to blunt the appreciation for the pain felt. The pain still continued, but the brain was drunk enough to be more accepting of it. The fetal downside was that narcotics could cause problems in interpreting and relying upon the validity of fetal heart tones, which tend to decrease in variability after a narcotic is given. Since decrease of variability in fetal heart rate is also a sign of fetal distress, this could lead to inaccurate decisions about the need for a C-section.
- Local blocks. The Pudendal nerve block was useful in numbing the area around the vagina and rectum, but it was uncomfortable to receive and could be incomplete, which wasn’t known until the moment it was most needed. The local injection, just at the site of an episiotomy or tear, was extremely spotty at times.
- Twilight sleep. This is what my mother had: Sedate ‘em, sleep ‘em, deliver ‘em, and wake ‘em up. So when I ask my Mom about my birth, she just says, “Mmmm…kind of fuzzy.” Not what today’s sensitivities expect.
- Hypnosis. A trend with more romance than practicality?
- Nothing. You can do “nothing” the right way or the wrong way. The right way is preparing with Lamaze or Bradley instruction. The wrong way is just showing up in labor without any practical knowledge of these two generally effective techniques and requesting no intervention.
The Marriage of Obstetrics and Anesthesia
Beginning in the 1970s, obstetrics and anesthesia began to fall into step, with both specialties seeking the same cross-specialty goals:
- Adequate pain relief, with “adequate” meaning enough relief as determined by the individual patient on a patient-by-patient basis.
- Safe pain relief offering safety for both the unborn and the mom, and with completely addressable side effects such that laboring women, if they were to fall into the small percentage of women experiencing complications from anesthesia, could rely on established interventions at the ready to undo or at least tremendously mitigate the effects of the complication.
- Pain relief which would neither interfere with the laboring and delivery process nor would be affected by the labor and delivery. The “wallops” of epidural dosing in the past often interfered with a woman’s ability to push when the time came (Stage II of labor, after complete dilation). This led to an increase in C-sections that otherwise wouldn’t have been necessary.
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