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Question for George; re epidurals
Topic Started: Feb 28 2009, 07:17 AM (365 Views)
jon-nyc
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Cheers
Is it ever 'too late' to give a pregnant woman an epidural? If so, why?

I've heard differing opinions on the subject.


(obviously when the placenta is in the pan its a little late, but you know what i mean)
In my defense, I was left unsupervised.
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dolmansaxlil
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HOLY CARP!!!
I'm not George (shocking, I know!).

When I had Liam, I had an extremely long early labour phase. It started on Monday morning - contractions every <10 minutes, enough that I couldn't sleep, but not enough that it was doing very much.

In the middle of the night Friday, they were growing progressively stronger. At around 4:30, it very suddenly hit me that I needed to get to the hospital RIGHT NOW. I checked into the hospital at 5:05. Signed in at the elevator and went up to whatever floor it was. They checked me and I was at 6cm. She sent me down to a room at the end of the hall - maybe 100 feet. On the way there, thinking about the "1cm an hour rule" I said to the nurse, "I can't do this for another 4 hours. I think I need an epidural." She said once I was in bed she'd find the doc for me. I got into bed and said, "You need to check me again." She laughed at me and told me that it had been less than 5 minutes and I was overreacting. "No. You need to check me." She rolled her eyes, but did as I asked. I was at 10. I delivered Liam at 5:36am - 30 minutes from when I checked into the hospital, and less than 15 minutes to go from 6cm to delivery.

In my case, 6cm was too late for an epidural :D But I'm not normal.

(By the way, I was told by the OBGYN after that if I chose to have a second child, I should either plan for a home birth from the start or they would admit me during that early labour stage. He said that he expects that I wouldn't make it to a hospital if things were to run similarly a second time. Glad I don't have to worry about it!)
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JBryan
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I am the grey one
It is never too late for pain killing drugs.
"Any man who would make an X rated movie should be forced to take his daughter to see it". - John Wayne


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George K
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(obligatory epidural joke: "Hell, I've known women who needed an epidural to get pregnant.")

Tough question, with no definite answer, other than this: by the time cervical dilation has completed to 10 cm, it's too late. By then, you're talking about pushing, and there's no way in hell that anyone can sit still long enough to let some clown stick a 17 gauge needle 2 1/2 inches into their backs aiming for a space that's about 1/16" thick by feel.

Having said that, it's really a judgment call on the part of the OB and the anesthesiologist. Most OBs, once the mom is at 7-8 cm will discourage an epidural for a number of factors. Among them are:

1) Things are going to go quicker (hopefully) and there's just not time to have mom sit for that long (it takes me about 15-30 min - even when I do it in 1 stick) before dilation really moves along.

2) Gravity. Our culture (I've never understood why) has women labor on their backs or sides. A woman's pelvis is designed built evolved to take advantage of gravity. Gravity pulls the kid down, speeding things along. I've had lots of women at 6-7 cm sit up and then, all of a sudden "WHOA! IT'S COMING NOW!" Having said that, not all anesthesiologists do epidurals with mom sitting, some do it on the side. I have my patients sit, because it's easier for me, and easier for me is always safer and better for the patient. With mom on the side, there's a good possibility that she'll be crooked in bed, and that makes finding the epidural space harder.

Hope that gives you a feel for what we deal with.

Now, there are certainly other considerations. If labor is not progressing, and mom's really tense, an epidural at 7-8 cm can really loosen things up, and allow a vaginal delivery, avoiding a c-section. That's happened to me dozens of times.

If junior isn't looking good on the fetal tracing, an epidural may relax mom as well, letting her breathe better, oxygenating the kid better. However, if the kid looks carppy, an epidural (which can cause a fall in BP) can worsen things as well.

Bottom line: Most anesthesiologists I know (and this includes the time when I worked at the university that did 4000 deliveries a year) would say 7-8 cm is just about too late, but there are other considerations, as I've said. Most would not put one in before active labor is established (usually 2-3 cm), though all of us have done so.

As far as technical aspects go, the two most important factors are the ability for mom to hold still (One time I walked into a room and mom said that there's no way she could hold still. I told her that there was no way that I could put in an epidural in that case, and she had a choice to make.) and maternal obesity (yes, we do have 5 1/2" needles).

Hope that muddies it up just enough for you.
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dolmansaxlil
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George - that was one of the things I insisted on - that I not be made to lay on my back. I used a squatting bar and it was amazingly successful. Laying down hurt like hell. Being upright still hurt like hell, but it felt like I was actually getting somewhere.

Liam was delivered by a resident, because the doc didn't get there in time. It was her first solo delivery, and she was shocked and amazed by how effective squatting was in delivery. She did have my lie down for the last push, because she wasn't comfortable "catching" in that position - but by that point, Liam didn't need a whole lot of encouragement so it was fine.
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RosemaryTwo
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HOLY CARP!!!
I insisted that the large mirrors, which were next to my hospital bed, be covered with sheets. Sheesh.
"Perhaps the thing to do is just to let stupid run its course." Aqua
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George K
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Finally
Mrs. George delivered daughters #1-3 without epidurals. She was a hell of a good Lamaze practitioner. It really works, just ask her.

She had an epidural for #4 and didn't like it. She says it made her feel like an observer not a participant. I think it goes with what you were saying about squatting, Dol. You're DOING something.

Another thing, once you have an epidural in, you're in bed for the duration. Yeah, there was a fad about "walking epidurals" about 8 years ago. We did 'em for a while. Patient's didn't like them because they were....ineffective.
A guide to GKSR: Click

"Now look here, you Baltic gas passer... "
- Mik, 6/14/08


Nothing is as effective as homeopathy.

I'd rather listen to an hour of Abba than an hour of The Beatles.
- Klaus, 4/29/18
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jon-nyc
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George, thanks for that, its very useful.
In my defense, I was left unsupervised.
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jon-nyc
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And Dol - thanks for scaring the hell out of me the story.
In my defense, I was left unsupervised.
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George K
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Finally
You think you're scared now?

Wait 16 years.
A guide to GKSR: Click

"Now look here, you Baltic gas passer... "
- Mik, 6/14/08


Nothing is as effective as homeopathy.

I'd rather listen to an hour of Abba than an hour of The Beatles.
- Klaus, 4/29/18
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dolmansaxlil
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HOLY CARP!!!
Actually, Liam's birth was the easiest part of the process. I keep telling people that I could give birth again without a problem - as long as someone else would do the pregnancy part and raise the child!

Seriously - having the "real" labour go so quickly was fantastic. The early labour stage was annoying, but definitely manageable. The transition part of labour was horrifically painful, but for me went so quickly that I was able to get through it without meds. I prefer quick and over the top agonizing to kind of agonizing over a long period of time.
"Your first 10,000 photographs are your worst." ~ Henri Cartier-Bresson

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DivaDeb
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I will do the pregnancies and raise the kids, Dol, if you'll pop them out. I am totally without ability in that area, something which my mother seems to enjoy telling people. Not that I'm bitter or anything.
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jon-nyc
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OK, as long as people are volunteering for their favorite part of the process...
In my defense, I was left unsupervised.
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dolmansaxlil
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HOLY CARP!!!
jon-nyc
Feb 28 2009, 10:59 AM
OK, as long as people are volunteering for their favorite part of the process...
:D

"Your first 10,000 photographs are your worst." ~ Henri Cartier-Bresson

My Flickr Photostream


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RosemaryTwo
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HOLY CARP!!!
I remember walking around for the first time after giving birth. I felt so light and free. I could walk again (not waddle) and inhale deeply, both at the same time.
"Perhaps the thing to do is just to let stupid run its course." Aqua
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DivaDeb
HOLY CARP!!!
I remember sitting, happily, at the bath demonstration. On a chair with a hard seat. While all the mothers who were better at birthin babies than me were either standing around the back of the room or gingerly perched on pillows. I thought I was quite blessed to have all my stitches where I could see them.
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