Becoming a mother has changed my practice as an anesthesiologist in many ways, one of which is in the management of mothers-to-be.
The idea of overnight call for most anesthesiologists conjures up thoughts of frequent requests for epidurals and the emergent cesarean sections. I can hear the laboring women begging for an epidural, screaming in agony as contractions become faster, quicker, and sharper. Although calls to the OB floor typically keep us busy throughout the night, it’s really the calls for ‘top-offs’ (bolus of local anesthetic) to help with breakthrough pain or a patchy epidural that are truly dreaded.
Given past training and experience, I was skeptical when patients would describe inadequate pain coverage or a persistent dull, crampy discomfort despite a successfully and skillfully placed epidural. Frustration on my part was inevitable after repeated pages resulted in unsatisfactory pain control for one reason or another.
Although these unsatisfied patients were few and far between, they often consumed many on-call hours and monopolized my nights and early mornings as a new anesthesiologist. Despite the resulting frustration, I remained convinced of the efficacy and the magic surrounding the renowned labor epidural anesthesia.
With this faith in my field, my own birth plan, of course, included an epidural. When the time arrived, I was ready to go. We got to the hospital in early labor, and, naturally, I immediately requested my epidural to be placed. Needless to say, I was only 1–2 cm at that point. The anesthesia resident entered the room and proceeded to rattle off the standard script of what to expect from the epidural and my potential risks. Without pause, I gave my consent, and the epidural was placed swiftly and without incident.
I used to tell patients on placement of the epidural that they will feel a “bee sting” as I injected local numbing medicine, and that they “won’t feel a thing.” That was until I gave birth to my son. Even in my experience as a patient with an uncomplicated epidural placement, I found my initial “bee sting” description to be less than accurate. After going through the experience, now I know there is a more accurate, better-serving way to describe things to my patients. I can now be more understanding and explain (for example): “You will feel a sharp pinch followed by a burning sensation as I inject numbing medicine. After that, you will feel pressure as I navigate to the right place. If you feel anything more than pressure, please let me know and I will stop and give more numbing medicine.”
As my labor progressed, I was able to get some sleep with the contractions feeling like a dull, crampy pain in my lower abdomen. At some point, a few hours into the epidural infusion, my legs began feel heavy. This made me nervous. I didn’t like the numbness and I asked for the epidural rate to be decreased. This was another moment of clarity for me as an anesthesiologist. When I felt a slight panic during when I couldn’t move my legs, I realized that there was truly a fine line between comfort and concern.
Labor continued to progress well, but as my son quickly descended, there was a point when his head lay directly on my sacral nerves. The pressure was excruciating. The anesthesiologist returned at my request, and we discussed the options and possibilities to tweak the epidural already in place. Despite barely being able to feel and move my legs, I could clearly feel the intense pressure in my back. We determined that an increased rate of the epidural infusion would only serve to numb my legs — an unnecessary and unwelcome result — and kept epidural at the same rate. Truly, the only way to relieve my pain would be to deliver.
During my own son’s birth, I was lucky to only endure the severe back pain my patients often call me to treat. I felt it for one hour until I was fully dilated and delivered a perfectly healthy baby! Phew. I was relieved to be out of pain and, of course, to meet my sweet boy.
Epidurals are not magical. They don’t work 100% of time. Labor is a dynamic and unique process, and an epidural is a wonderful tool to help facilitate easier labor. Even with extensive medical training and work experience that should have prepared me to know what to expect, I still had a frustrating pain management experience. I now realize the importance of carefully navigating expectations to achieve satisfactory care for our patients.
By being a patient myself, l gained a newfound appreciation for the marked variable patient labor experience. I no longer cringe when assigned to cover OB. Instead, I feel empowered, armed with the firsthand knowledge of what it is like to be a patient. I am better prepared to address my patients, to allay their concerns, and to properly manage their expectations. Being a patient often adds more perspective and is one example to remind doctors to take the opportunity to connect with and listen to patients’ needs.
Dr. Shayna Zachary is currently a practicing Anesthesiologist in Stamford, CT.