Epidural

Epidurals are interesting interventions. For thousands of years, laboring women have not had the option of having one. Yet since the advent of epidurals, many women consider it an essential component of childbirth. It is a charged topic. Upon meeting patients, almost everyone has an idea of what they want. Some emphatically want an epidural as soon as possible, others only want an epidural-free natural childbirth, a few want to see what happens. Obstetricians and anesthesiologists have their opinions too. And family members and friends and baby books and Internet discussion boards all have something to say.

I try to remain as neutral as possible. The most ethical thing is to explain, as plainly as possible, the risks, benefits, and expectations of an epidural. I have done the unfortunate wet tap leading to a post-dural puncture headache. I have also done dozens of perfectly working epidurals for wonderfully satisfied patients. I have also cheered for the woman who elects not to have any neuraxial blocks. I try to be as supportive as possible for women to choose what they want.

This is not the case for all anesthesiologists. In private practice, there is an incentive to do more epidurals because it is how anesthesia gets paid. Even ignoring financial incentive, there are patients in whom we may recommend an epidural. If a patient may possibly have an emergency requiring C-section and is a poor candidate for general anesthesia, we really press for an epidural so it could be used for surgical anesthesia during a crash section. For example, I saw a patient with poor neck mobility from prior surgery who was having a VBAC/TOLAC (vaginal birth after cesarian or trial of labor after cesarian) and recommended an epidural. The VBAC/TOLAC puts the patient at risk for uterine rupture, an indication for emergent surgery, and having an epidural in place for the C-section may reduce the risk of a failed intubation and complications from general anesthesia. (This being said, uterine ruptures can be so emergent that we'd default to general anyway.)