My wife Dana and I found out we were expecting our first child in the final months of my anesthesia residency in 1993. We were simultaneously inundated with good wishes and overwhelmed by more experienced friends with advice on how to prepare for the big day. For such a milestone event (and its inciting cause) that has been such a critical part of all of human history, one would think from the explosion of pregnancy books, and women’s magazine articles that the last generation or two practically invented it! As an anesthesiologist, I can confidently say that over these same generations we certainly have made the process a lot more comfortable. Unfortunately, because some people just won’t let others live their own lives, the topic of pain relief in labor is no stranger to controversy. No less an authority than the Holy Book itself makes this abundantly clear in Genesis 3:16 (New Living Bible): “To the women he said, “I will make your pains in childbearing very severe; with painful labor you will give birth to children.” And then to add insult to injury, it concludes – “Your desire will be for your husband and he will rule over you.” Try telling that to my wife. What we can learn about childbirth from Victoria’s Secret Perhaps, as a result of this biblical injunction, and the minimization of the experience women suffered during childbirth, efforts to mitigate the pain of labor were not taken seriously. In fact, at times in history, they were met with active resistance and shame. This has carried through to the modern era and popular culture! The world-renowned obstetrical anesthesia expert, Miranda Kerr, the Victoria’s Secret supermodel and ex-wife of the famed “Lord of the Rings” elf, Orlando Bloom, appeared on the cover of the August 2012 issue of Harper’s Bazaar, U.K. Inside she opined on the issue of childbirth. She told the magazine that she decided to have a natural birth without any pain medicine after watching baby-bonding videos. Kerr saw that babies without an epidural come out and go straight for the breast. “Then they showed the ones (babies) right after the epidural, and that didn’t happen,” Kerr said. “The baby was a little drugged up, and I was like, ‘Well I don’t want that.’ I wanted to give him the best start in life I could.” Undoubtedly, if I were fortunate enough to have been in that genetically privileged baby’s booties, I would have leaped like Legolas, straight for Amanda Kerr’s perfect breasts, drugged up or not. –Victoria’s real secret And for the record… here is Victoria’s real secret. The famed and fecund Queen was a huge fan of pain medicine for labor. One of the world’s first anesthesiologists, John Snow was celebrated for his ability to safely gas Her Highness senseless with chloroform during the births of her last two children. For this skill, and perhaps his success in identifying and halting the source of a horrific cholera epidemic in 1854, he was named by a 2003 poll of British doctors as “the greatest physician of all time”. Is it a coincidence that we have the word “snowed” to describe the state of blissful lack of awareness? I think not. Enter the childbirth education class So, as the months leading up to the birth of our baby ticked away, one of our recommended tasks was to take a childbirth education class. I must admit, as an anesthesia chief-resident with a fair amount of experience on the obstetric floor, I harbored doubts about the value of this undertaking. On the labor deck, I had seen numerous ridiculously elaborate birth-plans crafted in these classes burst into flame at the unyielding onslaught of the dragon’s breath of labor pain. In fact, the obstetricians and I often joked that the longer the birth plan, the greater the chance of a complex delivery followed by a C-section. I looked at the glossy brochure brought back from Dana’s first OB appointment, with the misty cover picture of a doe-eyed mother gazing down at her preternaturally chubby baby nestled against her breasts, its inner copy filled with words like “holistic” and “toxin-free”, and began to laugh in my usual snarky and cynical way… and was immediately shot down with “the look”. Here is some hard-earned marital advice: Do not laugh at the plans of your pregnant wife. Even if in the past she has been a gleeful co-conspirator with you against the smarmy idiocy of modern new-age baby marketing, just don’t do it. To this day, one of the biggest arguments in the history of our thirty-year marriage was about the exorbitant cost, and “real need” of designer crib linens and bumpers. Give up. Just buy them…and anything else she wants. The first day of class On the first day of birthing class, at the very literal threshold – the door of the room, empathy pillow in hand, Dana paused and made me solemnly swear that I would not let the teacher or anyone else in the class know that I was a doctor, and even worse, an anesthesia resident. She made me promise that I would listen attentively, that I wouldn’t snort derisively, roll my eyes, or sigh heavily… no matter what. In order to cement this deal, she gave me “the look” once again, and I knew I had no choice. I even agreed to meekly carry the empathy pillow, sit on the floor in a group circle, and go “hee-hee-hee, hoo-hoo-hoo” when prompted, with her back supported between my undignified splayed legs. I went to the front of the room and reluctantly introduced myself to the Birkenstock-shod doula-educator. She looked and smelled of patchouli oil, like someone straight from a Grateful Dead concert or an Oregon commune. She had a cloying voice, used the word “we” too much when she was talking to “me”. And she seemed a little too sweet, with a sharp edge I immediately recognized as pure passive-aggressiveness. I surveyed the room and the ten or so other couples scattered about. Some were bewildered and dazed newbies, and a few were clearly repeat parents, bored and all been-there-done-that. The first few childbirth classes were fine The first few classes were actually fine, nothing too controversial. Most of the topics were blandly informational, about such fascinating things as the early changes of pregnancy, lactation, mood swings, and must-have baby equipment. The routine was to present paired related topics, like nutrition and exercise, stretch marks, and skin-care – so far, so good. I was dutiful attentive and respectful. And, I took pains never to wear my scrubs to class, or discuss my day in the operating room. When asked, I said I was a student, which was sort of true. It would be an exaggeration to say that I enjoyed the class, but all in all it wasn’t horrible. So we continued to attend. And then one week, late in the curriculum, things took a decided turn for the worse. The childbirth class takes a turn for the worse On that fateful evening, we arrived a little tardy to find our tie-dyed pedagogue at the whiteboard busily scribbling away. The casual and friendly mood in the room was absent. Everyone seemed unusually hushed and serious. Her ample rear-end wiggled, and the dry-erase marker squeaked and squealed as she wrote. The two topics of the night were already delineated on either side of the board – doubly underlined in her flowery script: “Unexpected Fetal Demise” and… “Risks of Epidural Anesthesia” Dana shot me a warning glance as she could tell I was starting to get riled up. She painfully squeezed my hand after we sat down on the floor, no chairs allowed here, the empathy pillow accusingly thrust between us. Under “Risks of Epidural Anesthesia” the woman had drawn an elaborate diagram. In the middle was a big circle with the word “Epidural” in it. Several spokes extended from the center like a wagon wheel. At the end of each spoke were other circles, some big, some small. Then she started to write in each of them. In the first big circle she wrote, “Nerve damage, Possible Paralysis!” in the next circle, “Chronic back pain!” and the next, “ Use of –caine Drugs and Narcotics = Toxic, May Cause Future Addiction in Baby!” The next circle contained the words, “Interferes with Breast-Feeding and Attachment!” then, “C-Section nearly Guaranteed!” and then starkly, in the most prominent circle of them all, ”Death!!” Undoubtedly she felt the ultimate catastrophe gleefully deserved two exclamation points. Finally, in the tiniest, loneliest, most distant circle attached to the growing wheel of anxiety, she glumly wrote in small letters, “…you may get pain relief”. Clearly, no exclamation point granted here… and that was it for me. I lost it. Trip to the grocery store Looking back, I imagined myself like Clark Kent, tossing aside my nerdy eyeglasses, and ripping off my striped oxford button-down shirt to reveal my true identity, my scrubs with the crimson “S” beneath. Only in my case, it was an “A” for Anesthesia-Man, M.D.! In a single bound, I leaped to the board, grabbed the marker from the startled hippie-doula and drew my own wagon wheel with spokes and circles. I wrote “Trip to the Grocery Store” in the big central circle. And in the others, “Horrific Flaming Car Crash!”, “Kidnapped by Aliens and Anally probed!”, and “Poisoned by Botulism!” and so on. Finally, in the last small lonely circle, I wrote, “… you may get groceries”. Needless to say, we were invited not to come back to class after that. I could tell Dana felt relieved. She even sort of smiled at me. Later, in the hall, after class was over, and the hippie-doula was gone, several of the dads clapped me on the back and made me feel better. A few of the experienced moms mouthed, “Thank you!” Of course, I knew they all had epidurals with their first pregnancy. I even recognized some of them as ex-patients; and as far as I could tell, they were definitely alive, they all walked just fine, and not one of them had cocaine-addled junkie toddlers in tow. Diane Sklar, MD: As a practicing Ob/Gyn, I have worked with many midwives, doulas, and others who provide childbirth support. My experience with them is that most of the time, the autonomy of the patient and partner as well as cooperation and communication with the care team is handled with respect and without judgment. It is notable that in-hospital births have a high epidural use (I think around 55-70 % depending on the hospital) likely reflecting patient (as well as provider) preference. I do find that childbirth classes that are taught by Labor and Delivery nurses and/or midwives who work in hospital or birth center settings tend to be the most comprehensive and thorough. It is important that the instructors of these classes understand the patient population they are serving. In my SF Bay Area practice the patients tend to be older, multiethnic, often well-educated people who tend to have one or at most two children. The goal of these classes is to educate, inform, cooperate, and respect the desires of the parents-to-be, always putting the safety of the mother and baby at the forefront. Margaret Cary, MD: When I did OB in my medical practice it seemed that everyone’s grandmother had been paralyzed by an epidural. Curiously, I never met any of them. Given the numbers, I should think they’d be at every street corner. And that the numbers would show somewhere in statistics. My observation is that pregnant women are fair game for each of the following: 1. People touching their abdomens without permission, and 2. Hearing all the horror stories around pregnancy and delivery. Source
