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Old 02-11-2011, 07:20 PM
 
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 Education should come from both sides of the coin, making sure that women know that it might not be that bad, or that it MIGHT be that bad.  Educate them to try that there are a large variety of pain relief methods to try, from walking to epidurals, and what the risks and benefits of all of them are, THAT is the best option. 

 


The problem with simple education on the risks and benefits is that it does not take into account the fact that, in most hospitals, in most families, making those choices is not easy. I have seen many women who understood the risks and did not want an epidural end up with one because their partner was beside himself panicking while she was screaming or because of a vaginal exam that told her she was not up to par. Educating women about what they will need to fight to avoid the epidural is one thing and he does yield some limited success (just look at all the women here who managed to get their natural birth in hospitals), the only way to make a true difference is to get rid of those obstacles. That does involve an entire paradigm shift for many care providers and institutions so instead we end up with people trying to minimize that "guilt" (which should be really be felt by those hospitals and not their patients) and grasping at statistical trickery to convince people that there really is no problem.

The fact that you make the assumption that I am talking about educating women on what they need to fight to avoid it, is part of the problem and part of where the guilt come from.  The purpose of the education is to help women make choices, not automatically to avoid epidurals.  Many women look at the risks and decide that the epidural is for them.  And that's ok.  But being told that the education is to help them avoid it certainly implies that they are not supposed to want it, hence where guilt comes from. 

 

And once again, there's the assumption that a fight has to take place at all.  If you go into any situation expecting to have to fight, you are probably going to get a fight.  But if you go into the situation with an open mind, you are more likely to get your way without any opposition at all.  It's been my experience on this board that a lot of folks here go into birth at a hospital expecting a fight and are looking for opposition that isn't necessarily there.
 


That was meant as " Educating women about how they will need to fight if they want to avoid the epidural..."

 

Every single woman I have met who went into the hospital without a resolved determination to fight for a natural birth ended up with an epidural. I even witnessed a doctor trying to hold down my sister as the baby was crowning to get the epidural in because she had a fast labour and it was a big race to get it done in time...



I have to be honest aside from own my first birth (no epidural btw) , where a doctor rolled her eyes at me then quickly gave me a through and through episiotomy that I was too exhausted to even know I HAD until I discovered stitche a few days later and asked my mom about it all because I was passing out between contractions and just didn't think I could go on anymore...I have NEVER seen this kind of lack of professionalism in a hospital setting (L&D or toherwise) directed at a patient

 

and frankly..having worked in emergency services for going on 10 years I've seen some very unprofessional things..but never anything that would involve restraint of a patient beyond a psych with a psychotic break..

I have witnessed healthcare professionals try to convince a patient they needed something (when they were genuinely concerned not financialy motivated) life saving but never for simple pain relief

you wanna suffer...go for it has always been the attitude I've seen.

 

but then again...epidural goes to the anesthesia department at every hospiatl here ...not L&D and definitely not the OB who generally has a two flat rates, one for cesarean, one for normal vaginal delivery and for all prenatal appointments (btw the difference between the rates at the practice I'm currently going to is $500 dollars..which is peanuts)

 

 

 

I feel an incredible amount of irrational guilt for having had two epidurals...my own PCP had a spinal headache from an epidural and has actually stated she'd rather go through natural childbirth rather than ever experience that again..this weighs heavily on me because I trust her judgement fairly implicitly..not to be confused with complacently, I question that Dr a lot because shes always made me feel her equal to her credit. 

 

Ive had a full epidural and a walking epidural...I'd say that if I had been a first time mom I might not of figured out how to push with the full epidural...as it was I had to watch my abdomen for contractions to know when to so thats a strike against it for sure

..the walking epidural was pure heaven, for the first time I got to feel the baby's body move through my pelvis and understand what was going on...actively push while squatting, be alert, be happy..not want to kill the staff for imagined insults...and ENJOY my new baby

 

both of the epidural babies were much quicker labors and that really really helped me cope with caring for a newborn

 

by no stretch of the imagination am I saying everyone should get an epidural..but much like another hot topic among womens healthcare..

those that are against epidural give everyone else a sort of quiet crap to those that get them, like you didn't earn a special merit badge or something...but those that get them don't think everyone should

 

I think for every medical procedure including this one TRUE informed consent should be given and it rarely is honestly so that each woman can weigh the pros and cons

kwim?

 

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Old 02-11-2011, 08:47 PM
 
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 Every single woman I have met who went into the hospital without a resolved determination to fight for a natural birth ended up with an epidural. 

 See, and I have had the opposite experience, every woman I have met who gave birth in a hospital and didn't want an epidural, had no problems with the hospital staff whatsoever, including my own 3 births. 

 

So where does that leave us but trading anecdotal stories that really aren't proof of anything.  Just because YOU and others you might know might have had issues, that does NOT mean that it's a universal truth.  Just as the fact that I and the women I know haven't had issues doesn't make it a universal truth either.  I realize that there are @**hole docs out there who are unprofessional and push crap on their patients, just like there are midwives who neglect their paitents and there are cops who drive drunk while on the job and kill people.  However, for every crappy doc or midwife or cop, there are hundreds of great ones. 

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Old 02-12-2011, 09:12 AM
 
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For example: there is a risk of driving to the hospital. So is home birth safer? Well, the most recent data shows a 2 to 3-fold greater risk of death for the baby at home compared to hospital.

  



If you are citing the Wax paper as valid evidence, I'm not sure I would trust the validity of the conclusions in your book.  Is this the type of "study" that you believe is good evidence?


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Old 02-12-2011, 09:49 AM
 
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 Every single woman I have met who went into the hospital without a resolved determination to fight for a natural birth ended up with an epidural. 

 See, and I have had the opposite experience, every woman I have met who gave birth in a hospital and didn't want an epidural, had no problems with the hospital staff whatsoever, including my own 3 births. 

 

So where does that leave us but trading anecdotal stories that really aren't proof of anything.  Just because YOU and others you might know might have had issues, that does NOT mean that it's a universal truth.  Just as the fact that I and the women I know haven't had issues doesn't make it a universal truth either.  I realize that there are @**hole docs out there who are unprofessional and push crap on their patients, just like there are midwives who neglect their paitents and there are cops who drive drunk while on the job and kill people.  However, for every crappy doc or midwife or cop, there are hundreds of great ones. 



Who is claiming knowledge of universal truth?

 

This really has nothing to do with doctors being @**holes or good. The responsibility is shared by the entire medical institution as well as by society at large.


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Old 02-12-2011, 06:32 PM
 
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Dr. Grant: I share mntnmom's question. Could you possibly provide citations for particular studies or at least suggestions about search terms? I did, as you suggest, search PubMed and the results I found were neither particularly recent nor particularly supportive of your positions. To give you an idea, here are the articles that I found (sorry so long):Can Fam Physician. 2006 April 10; 52(4): 419–421.Does epidural analgesia increase rate of cesarean section?Michael C. Klein, MD, CCFP, FAAP, FCFPConclusion: Contrary to the conclusion of the Cochrane meta-analysis of EA compared with narcotic analgesia, EA given before the active phase of labour more than doubles the probability of receiving a CS. If given in the active phase of labour, EA does not increase rates of CS. Meta-analysis can be helpful and timesaving for busy practitioners, but we need to be vigilant about which studies get into the meta-analyses and ask ourselves if they make clinical sense. And, unfortunately, we need to continue to read the individual studies that make up meta-analyses—especially if they are likely to actually change practice—to determine whether study conditions represent our clinical reality.Am J Obstet Gynecol. 1997 Dec;177(6):1465-70.Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia.Bofill JA, Vincent RD, Ross EL, Martin RW, Norman PF, Werhan CF, Morrison JC.STUDY DESIGN: Active labor was confirmed in nulliparous women by uterine contractions, cervical dilatation of 4 cm, effacement of 80%, and fetopelvic engagement. Patients were randomized to one of two groups: epidural analgesia or narcotics. A strict protocol for labor management was in place. Patients recorded the level of pain at randomization and at hourly intervals on a visual analog scale. Elective outlet operative vaginal delivery was permitted.CONCLUSIONS: With strict criteria for the diagnosis of labor and with use of a rigid protocol for labor management, there was no increase in dystocia-related cesarean delivery with epidural analgesia.Anesthesiology. 1997 Sep;87(3):487-94.Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor.Sharma SK, Sidawi JE, Ramin SM, Lucas MJ, Leveno KJ, Cunningham FG.CONCLUSIONS: Epidural analgesia was not associated with increased numbers of cesarean delivery when compared with a suitable alternative method of analgesia.Obstet Gynecol. 1996 Dec;88(6):993-1000.Association of epidural analgesia with cesarean delivery in nulliparas.Lieberman E, Lang JM, Cohen A, D'Agostino R Jr, Datta S, Frigoletto FD Jr.CONCLUSIONS: Epidural analgesia may increase substantially the risk of cesarean delivery. Although the causal nature of this association remains open to debate, prenatal care providers should routinely discuss the risks and benefits of epidural analgesia with women during their pregnancies so that they can make informed decisions about the use of pain relief during labor.Am J Obstet Gynecol. 1993 Oct;169(4):851-8.The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial.Thorp JA, Hu DH, Albin RM, McNitt J, Meyer BA, Cohen GR, Yeast JD.CONCLUSIONS: In a randomized, controlled, prospective trial epidural analgesia resulted in a significant prolongation in the first and second stages of labor and a significant increase in the frequency of cesarean delivery, primarily related to dystocia.Am J Obstet Gynecol. 1989 Sep;161(3):670-5.The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women.Thorp JA, Parisi VM, Boylan PC, Johnston DA.Abstract … The incidence of cesarean section for dystocia was significantly greater (p less than 0.005) in the epidural group (10.3%) than in the nonepidural group (3.8%). There remained a significantly increased incidence (p less than 0.005) of cesarean section for dystocia in the epidural group after selection bias was corrected and the following confounding variables were controlled by multivariate analysis: maternal age, race, gestational age, cervical dilatation on admission, use of oxytocin, duration of oxytocin use, maximum infusion rate of oxytocin, duration of labor, presence of meconium, and birth weight. The incidence of cesarean section for fetal distress was similar (p greater than 0.20) in both groups. There were no clinically significant differences in frequency of low Apgar scores at 5 minutes or cord arterial and venous blood gas parameters between the two groups. This study suggests that epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparous women.ETA: For the record, I don't think any woman should feel guilty about choosing an epidural or other pain relief. Nor do I think she should be made to feel stupid or pigheaded for avoiding one. It's a personal choice. But seeing as how it's a personal choice I'll be making in about 7-8 months, I'd like to know the facts as best I can.

Thank you for your question. To read the literature properly, it helps to have a background in science, statistics, etc. It's not an easy task for a layperson to critically evaluate various studies. There are so many factors that need to be considered from study design to data to interpretation of the data and everything in between. I've concluded, as have the majority of other scientists and physicians who have looked at these studies, that there is absolutely no causal link between epidurals and cesareans. Is there an association? Most certainly! But causation? No! Some of the articles you quoted are flawed scientifically. But it's going to be very difficult for a lay person to figure that out, though, as I mentioned. If you want to take a look at one paper that examines this issue, try the one I've pasted below. It's quite convincing.

For me, the epidural - cesarean question has become a non-issue. I think it's been proven beyond a doubt that epidurals, even when given very early in labor - as I recommend - don't increase the risk of a cesarean. I'd like people to focus on the other aspects of epidural pain relief, particularly, the potential benefits of pain relief for the mother and baby, apart from the avoidance of suffering e.g., potential reduction in incidence of postpartum depression and PTSD). This is what I write about in my book, because the advantages of epidurals are seldom considered.

 

Good luck to you!

 

Am J Obstet Gynecol. 2000 Oct;183(4):974-8.

The effect of a rapid change in availability of epidural analgesia on the cesarean delivery rate: a meta-analysis.

Segal S, Su M, Gilbert P.

Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

Abstract

OBJECTIVE: This study was undertaken to quantitatively estimate the effect of a rapid introduction or withdrawal of on-demand epidural analgesia on the cesarean delivery rate.

STUDY DESIGN: MEDLINE and meeting abstracts were searched for studies reporting the cesarean delivery rate immediately before and after a rapid change in the availability of epidural analgesia. Nine studies reporting data on 37,753 patients were selected. Meta-analysis was performed to estimate the means and 95% confidence intervals for the changes in rates of total cesarean deliveries, cesarean deliveries among nulliparous women, cesarean deliveries for dystocia, and operative vaginal deliveries.

RESULTS: There was no significant change in the overall cesarean delivery rate with an increase in the availability of epidural analgesia. Similarly, the rates of cesarean deliveries among nulliparous patients, of cesarean deliveries for dystocia, and of operative vaginal deliveries did not significantly differ between periods of high and low epidural analgesia availability.

CONCLUSION: A rapid change in the availability of epidural analgesia is not associated with any increase in the cesarean delivery rate.

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Old 02-12-2011, 06:45 PM
 
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 Since everyone knows and agrees that epidurals are without doubt the best way to releive the pain of childbirth, how can we design a study that randomizes women to a group that is denied the best pain relief?

 


That's hilarious and tragic at the same time.

 

 

Dr Grant, I wish we could have this conversation face to face to get to the bottom of it all. Why do you think pain relief should be common or needed for giving birth?

I don't find my statement hilarious or tragic. It's merely a statement of fact. For most women, labor is the most severe pain they will experience in their lives. That is a scientific fact. It's not an opinion. Sure, for some women, the pain of labor and delivery isn't so bad. As I mention in my book, some women actually enjoy it to such a degree that they achieve orgasm at the moment of delivery. But facts are facts: for MOST women, labor is the most severe pain that they will ever experience. If a woman doesn't want pain relief, either because her labor doesn't hurt or because she would rather have the "full experience," more power to her! But for the overwhelming majority of women who experience excruciating pain during labor and delivery, of course I think they should have the right to have their pain relieved. I'm a physician. It's my duty to care for people. Of course what I propose is quite commonsensical: I suggest that women who want an epidural get it BEFORE the pain becomes severe. Why suffer needlessly?

 

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Old 02-12-2011, 06:47 PM
 
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 Every single woman I have met who went into the hospital without a resolved determination to fight for a natural birth ended up with an epidural. 

 See, and I have had the opposite experience, every woman I have met who gave birth in a hospital and didn't want an epidural, had no problems with the hospital staff whatsoever, including my own 3 births. 

 

So where does that leave us but trading anecdotal stories that really aren't proof of anything.  Just because YOU and others you might know might have had issues, that does NOT mean that it's a universal truth.  Just as the fact that I and the women I know haven't had issues doesn't make it a universal truth either.  I realize that there are @**hole docs out there who are unprofessional and push crap on their patients, just like there are midwives who neglect their paitents and there are cops who drive drunk while on the job and kill people.  However, for every crappy doc or midwife or cop, there are hundreds of great ones. 


Exactly! I couldn't agree with you more. Comparison of anecdotes is a pointless exercise.
 

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Old 02-12-2011, 07:41 PM
 
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Are your claims about the majority of women wanting pain relief anecdotal or evidence based? Do you recognize the variation on perceptions of need for pain relief depending of where the birth is occurring and who is present? What are your thoughts on the cultural aspects of pain in childbirth?


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Old 02-12-2011, 08:31 PM
 
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Are your claims about the majority of women wanting pain relief anecdotal or evidence based? Do you recognize the variation on perceptions of need for pain relief depending of where the birth is occurring and who is present? What are your thoughts on the cultural aspects of pain in childbirth?

Don't misquote me. This was my response to you:

For most women, labor is the most severe pain they will experience in their lives. That is a scientific fact. It's not an opinion. Sure, for some women, the pain of labor and delivery isn't so bad. As I mention in my book, some women actually enjoy it to such a degree that they achieve orgasm at the moment of delivery. But facts are facts: for MOST women, labor is the most severe pain that they will ever experience. If a woman doesn't want pain relief, either because her labor doesn't hurt or because she would rather have the "full experience," more power to her! But for the overwhelming majority of women who experience excruciating pain during labor and delivery, of course I think they should have the right to have their pain relieved. I'm a physician. It's my duty to care for people. Of course what I propose is quite commonsensical: I suggest that women who want an epidural get it BEFORE the pain becomes severe. Why suffer needlessly?

Where in there did I "claim" that the majority of women want pain relief"? My point is simply that the pain of childbirth is the most severe pain that most women ever experience in their entire lives. If you ask a whole bunch of women who've had a whole lot of life experiences what the worst pain they ever experienced was, most of them will tell you it was childbirth. Nothing anecdotal about this. Just facts. If you want to read the science behind this, look at Dr. Melzack's work.

Cultural aspects of pain in childbirth? Forget about my thoughts - just look at the facts: In cultures simce the beginning of recorded history, we know that chilbirth hurt. It's always hurt. It's mentioned in the Bible, it's mentioned in literature from cultures throught the world. It appears in drawings and art throughout the ages. Childbirth hurts.

Facts 

 

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Old 02-12-2011, 09:10 PM
 
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  I suggest that women who want an epidural get it BEFORE the pain becomes severe. 

 This is something I am curious about.

 

I have taken lots of pain meds in my time.  I have had 7 teeth pulled, 3 root canals and countless other dental issues, requiring some form of narcotic pain relief either before or after, not to mention pain meds for afterbirth pains.  In addition, I get migraines and take meds for that, after having tried out several different options.

 

And in reading up on all the stuff I have taken (got any questions about vicoden, hydrocodone or vicoprophen?:-) )  something that is discussed quite a bit is that it's best to take the pain meds before the pain gets severe.  That pain meds work best on the pain the earlier you take them. 

 

Is this something that's true for epiduals as well?  An epidural is a different kind of pain killer, right? 

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Old 02-12-2011, 09:35 PM
 
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"Dr Grant" (I am addressing you in quotes, because I would hope that a busy Director of OB Anesthesia would not be scouring forums,, but would probably assign a proxy to scour the forums to respond in his stead):

 

#1 Your condescending post earlier disregards the fact that mothers can, AND DO, have backgrounds in the sciences.  Some of us are not laypeople.  Though I thoroughly resent the implication that laypeople are incapable of understanding peer-reviewed research.

 

#2  It's laughable that you would indict the study designs for the numerous articles that capretta referenced, and then post a single article supporting your position that is a meta-analysis.  I certainly would think someone like you (who had just insulted the women on this board as being incapable of understanding the results of the studies you'd encouraged them to look up in the first place), would know how dubious the results of that meta-analysis appear when the inherent bias of the authors ("Department of Anesthesiology") means that it's very likely errors in choice or use of a protocol to encourage a particular result was in play.  Frankly, with the whole profession of Obstestric Anesthesiology dependent on the money that the vast number of epidurals bring in, I doubt anyone affiliated with the profession can deliver a convincingly objective meta-analysis.

 

If you really are Dr. Grant, I grossly misjudged your character in my earlier post when I said you sounded like a nice person.  For Dr. Grant's reputation's sake, I hope you are merely impersonating him (whether as an approved proxy or not).  I'd hate to think someone so smug and condescending -- not to mention so blind to his own bias -- thought he was doing women some wonderful favor by advocating the perpetuation of his own profession.

 

I'm not saying epidurals are wrong at all.  What I think is wrong is for a wolf in sheep's clothing to sell women on them as safe, when in reality his true motive may be to ensure that the natural birth movement doesn't get the chance to reduce the money and prestige of his profession.  That's gross.

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Old 02-13-2011, 12:13 AM
 
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#2  It's laughable that you would indict the study designs for the numerous articles that capretta referenced, and then post a single article supporting your position that is a meta-analysis.  I certainly would think someone like you (who had just insulted the women on this board as being incapable of understanding the results of the studies you'd encouraged them to look up in the first place), would know how dubious the results of that meta-analysis appear when the inherent bias of the authors ("Department of Anesthesiology") means that it's very likely errors in choice or use of a protocol to encourage a particular result was in play.  Frankly, with the whole profession of Obstestric Anesthesiology dependent on the money that the vast number of epidurals bring in, I doubt anyone affiliated with the profession can deliver a convincingly objective meta-analysis.

 

 

uh, you do know that the people that are most likely to research a topic are those with a highly educated specialty in the topic? and that those people are going to have their methods scrutinized by other people highly educated in the specialty? and that scientific publication is the first step of verification? something isn't published because it's "true", it's published because it meets scientific scrutiny at which point an on-going debate takes place if the results are found to be of interest.

 

as for the italics... you realize that you've just said that the people that know the most about a subject are incapable of studying it, right? i mean, right there, you've essentially written off the entire scientific community and process (not the scientifc "method" as that doesn't really exist) because of bias.


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Old 02-13-2011, 12:15 AM
 
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Actually in the Listening to Mother survey, it was very clear that coercion and guilt ARE a part of modern day obstetrics and that women do not like it, but feel trapped.  I believe that every woman should be able to make choices for herself, but after ten years working in birth I can say without hesitation that no woman fights for the right to get her epidural.  MANY women, however, have to fight tooth and nail to claw their way to an un-induced, un-hindered, un-medicated birth they desire.  AND our cesarean rate is unsupportable.  It is climbing because of interventions that are not supported by the literature and women and children are being hurt by it. 

 

And I speak from personal experience (having 50mcg of cytotec for 8 doses on a twin distended uterus WITHOUT informed consent and indeed lying to me about which drug was being used) when I say that in order to get natural and unhindered birth, I had to go to home birth for my later pregnancies and with a later very preemie pregnancy I literally had to tell a doctor that I would charge him with assault if he did XYZ without my consent and to go find a waiver if that would make him happy. I ended up signing three waivers while trying to birth and care for my babies in that hospital.  Please don't tell me that women get "choice".  They get the choice you think is best easily, the choice they want with great emotional and mental cost.

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Old 02-13-2011, 12:21 AM
 
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Not for every woman.  In fact my unmedicated labors were work, but I would NOT characterize them as pain at all.  What was painful was pushing.  Really painful for me.  But over in under 12 minutes each of the three times I did it after my first awful cytotec/pitocin/narcotic/epidural/3rd degree episiotomy/vacuum nightmare.  But ask me which of my four births was worst, the one handled with your own special brand of intervention or the ones I handled through my own strength and intuition, supported by a midwife who believed in me and gave me the tools to do so...

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Old 02-13-2011, 07:49 AM
 
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Originally Posted by happysmileylady View Post

 

Quote:
  I suggest that women who want an epidural get it BEFORE the pain becomes severe. 

 This is something I am curious about.

 

I have taken lots of pain meds in my time.  I have had 7 teeth pulled, 3 root canals and countless other dental issues, requiring some form of narcotic pain relief either before or after, not to mention pain meds for afterbirth pains.  In addition, I get migraines and take meds for that, after having tried out several different options.

 

And in reading up on all the stuff I have taken (got any questions about vicoden, hydrocodone or vicoprophen?:-) )  something that is discussed quite a bit is that it's best to take the pain meds before the pain gets severe.  That pain meds work best on the pain the earlier you take them. 

 

Is this something that's true for epiduals as well?  An epidural is a different kind of pain killer, right? 

 

 There are different types of medication that can be administered in an epidural. But your thoughts are exactly right. It's definitely better to take pain relievers BEOFRE the pain begins. When's the last time time you were at the dentist and told the her/him to start drilling for a while before giving you the local? Let me guess: Never? Becuase that would be plain silly! But women in labor do that all the time. I'm not talking about those women that don't want any medications and are committed to a "natural birth." I'm talking about women who think theat they want an epidural, or are sure that they want an epidural, but they wait until the pain becomes excruciating before they get it. It makes absolutely no sense. But this is standard practice. I'm trying to explain that it shouldn't be. If you want pain relief for labor, why suffer at all? As I point out in my book, pain itself has a lot of really bad effects for the mother and the baby. In general, for various reasons, you're exactly right - it's better to tak pain meds before the pain becomes severe.

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#2  It's laughable that you would indict the study designs for the numerous articles that capretta referenced, and then post a single article supporting your position that is a meta-analysis.  I certainly would think someone like you (who had just insulted the women on this board as being incapable of understanding the results of the studies you'd encouraged them to look up in the first place), would know how dubious the results of that meta-analysis appear when the inherent bias of the authors ("Department of Anesthesiology") means that it's very likely errors in choice or use of a protocol to encourage a particular result was in play.  Frankly, with the whole profession of Obstestric Anesthesiology dependent on the money that the vast number of epidurals bring in, I doubt anyone affiliated with the profession can deliver a convincingly objective meta-analysis.

 

 

uh, you do know that the people that are most likely to research a topic are those with a highly educated specialty in the topic? and that those people are going to have their methods scrutinized by other people highly educated in the specialty? and that scientific publication is the first step of verification? something isn't published because it's "true", it's published because it meets scientific scrutiny at which point an on-going debate takes place if the results are found to be of interest.

 

as for the italics... you realize that you've just said that the people that know the most about a subject are incapable of studying it, right? i mean, right there, you've essentially written off the entire scientific community and process (not the scientifc "method" as that doesn't really exist) because of bias.


Well put.
 

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"Dr Grant" (I am addressing you in quotes, because I would hope that a busy Director of OB Anesthesia would not be scouring forums,, but would probably assign a proxy to scour the forums to respond in his stead):

 

#1 Your condescending post earlier disregards the fact that mothers can, AND DO, have backgrounds in the sciences.  Some of us are not laypeople.  Though I thoroughly resent the implication that laypeople are incapable of understanding peer-reviewed research.

 

#2  It's laughable that you would indict the study designs for the numerous articles that capretta referenced, and then post a single article supporting your position that is a meta-analysis.  I certainly would think someone like you (who had just insulted the women on this board as being incapable of understanding the results of the studies you'd encouraged them to look up in the first place), would know how dubious the results of that meta-analysis appear when the inherent bias of the authors ("Department of Anesthesiology") means that it's very likely errors in choice or use of a protocol to encourage a particular result was in play.  Frankly, with the whole profession of Obstestric Anesthesiology dependent on the money that the vast number of epidurals bring in, I doubt anyone affiliated with the profession can deliver a convincingly objective meta-analysis.

 

If you really are Dr. Grant, I grossly misjudged your character in my earlier post when I said you sounded like a nice person.  For Dr. Grant's reputation's sake, I hope you are merely impersonating him (whether as an approved proxy or not).  I'd hate to think someone so smug and condescending -- not to mention so blind to his own bias -- thought he was doing women some wonderful favor by advocating the perpetuation of his own profession.

 

I'm not saying epidurals are wrong at all.  What I think is wrong is for a wolf in sheep's clothing to sell women on them as safe, when in reality his true motive may be to ensure that the natural birth movement doesn't get the chance to reduce the money and prestige of his profession.  That's gross.

#1 - I stand by what I said. lt's difficult for a layperson to evaluate peer-reviewed research. And it may be difficult for scientists to evaluate peer-reviewed research in specialties that are not their own. The person best able to evaluate it is a specialist in that area.

#2 - Instead of laughing, if you're a "scientist," then act scientifically and investigate. Read the meta-analysis I suggested and read all of the original studies that were analyzed in the meta-analysis. If you do so, in a scientific, objective, and unbiased manner, I think you will come to the inescapable conclusion that epidurals do not cause cesareans. There are many, many studies that could be discussed regarding this issue. But you're right, I am a very busy man, and there is no way I can take the time to dissect each and every one of them here, pointing out which have methodological errors, which are well-done, etc. I offered the one reference because it is quite compelling, and well-done. If you're truly a scientist, you'll read it and evaluate it. But based on your comments, I suspect that you'd prefer not to have your deep-seated beliefs challenged by some facts.

#3 - Your first impression was correct. Dr. Grant is indeed a very nice guy who has dedicated his professional life to relieving pain. He has no problem with women who want to birth "naturally," but he firmly believes that all women should have access to accurate information so that they can make a decision that's right for them. And he's noticed that there's a whole lot of misinformation out there that he's trying to counter with facts.

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dr. gilbert, thanks for coming here to talk about your book! i'm very happy to see something like this published, i agree that there is a huge need for accurate information on childbirth.

 

also, as someone who has taken the time to really thoroughly read through the medical literature on vaccination, VBAC, and homebirth, i haven't even attempted to look at the information on epidurals. there is so, so much, that i'm not sure it's possible to make a properly informed opinion. ok, i guess it'd be possible, but it'd take about as long as it took me to research vaccines (hundreds of hours. good thing i don't have other hobbies!). i just think that your average first time mom will not have the time for that. besides, i have a strong science and math background, so catching up on those skills would add even more time. this, for me, is one of those questions i'm happy to leave to the experts

 

i'm curious, does the book address the idea that epidurals have made c-sections safer by reducing the need for general anesthesia? i've wondered if that benefit has ever been quantified.

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  I suggest that women who want an epidural get it BEFORE the pain becomes severe. 

 This is something I am curious about.

 

I have taken lots of pain meds in my time.  I have had 7 teeth pulled, 3 root canals and countless other dental issues, requiring some form of narcotic pain relief either before or after, not to mention pain meds for afterbirth pains.  In addition, I get migraines and take meds for that, after having tried out several different options.

 

And in reading up on all the stuff I have taken (got any questions about vicoden, hydrocodone or vicoprophen?:-) )  something that is discussed quite a bit is that it's best to take the pain meds before the pain gets severe.  That pain meds work best on the pain the earlier you take them. 

 

Is this something that's true for epiduals as well?  An epidural is a different kind of pain killer, right? 

 

 There are different types of medication that can be administered in an epidural. But your thoughts are exactly right. It's definitely better to take pain relievers BEOFRE the pain begins. When's the last time time you were at the dentist and told the her/him to start drilling for a while before giving you the local? Let me guess: Never? Becuase that would be plain silly! But women in labor do that all the time. I'm not talking about those women that don't want any medications and are committed to a "natural birth." I'm talking about women who think theat they want an epidural, or are sure that they want an epidural, but they wait until the pain becomes excruciating before they get it. It makes absolutely no sense. But this is standard practice. I'm trying to explain that it shouldn't be. If you want pain relief for labor, why suffer at all? As I point out in my book, pain itself has a lot of really bad effects for the mother and the baby. In general, for various reasons, you're exactly right - it's better to tak pain meds before the pain becomes severe.



I think to some degree you're being dismissive ...and I support use of epidurals with informed consent (real, unbiased information). I for one have had a sense of guilt having had epidurals and agree that a standard "full epidural" vs a "walking epidural" are two different animals. I think laboring for some time without the epidural is beneficial in one aspect for experience but more importantly it is often hospital policy to keep a mother on a gurney/be with continuous monitoring (bp, ringer iv, 02 sat, fetal hr, possible catheterization) and of course for liability. This is not a good position to labor in for fetal descent, this doesn't help malpositioned babies get into a better position for all involved, this increases the risks for interventions.I think this practice needs some "tweaking" in order to really help reduce risks of epidurals leading to more caesareans, vacumn extraction, low forceps etc.

 

I will add a qualifier to that and say that I was very adamant in my second epidural birth (walking epidural) that I still be allowed to move around at will and whim and had none of the above problems/risks but the only reason I knew I could fight for this, and it was an argument, was because I am acutely aware of patient rights in my state having worked on the other side of things and being a particularly aggressive patient advocate.

 

 

I think more women need to know what their rights are and not be bullied by anyone and that this is really the core of the matter.I see over and over again on this board that women have grown to mistrust the medical community because of bad medical attention they have received. This to me is a huge problem for a variety of reasons not least of which childbirth where women are affraid even at a home birth to call someone in case of an emergency.

 

 I also am a vaguely offended that you would imply that women (especially on this board) can't possibly understand what statistics mean or how peer reviewed studies are conducted. This is naive on your part. There are quite a few nurses, doctors and midwives on this board let alone many other sciences (I'm neurobiology and paramedic sciences, my husband a chemical engineer). The M.D. isn't the only area of study that study these things/learn them in college and apply them in their daily working careers. Perhaps your own patients can't make rational informed choices and for that I'm truly sorry. Also I think you ignore where people might have other strengths that may or may not apply to the matter at hand. For instance in absolutely any medical emergency where there isn't a controlled enviroment I'd bet my home that I react better and more efficiently than you do..not that this applies here but hopefully you get my point.

 

 

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dr. gilbert, thanks for coming here to talk about your book! i'm very happy to see something like this published, i agree that there is a huge need for accurate information on childbirth.

 

also, as someone who has taken the time to really thoroughly read through the medical literature on vaccination, VBAC, and homebirth, i haven't even attempted to look at the information on epidurals. there is so, so much, that i'm not sure it's possible to make a properly informed opinion. ok, i guess it'd be possible, but it'd take about as long as it took me to research vaccines (hundreds of hours. good thing i don't have other hobbies!). i just think that your average first time mom will not have the time for that. besides, i have a strong science and math background, so catching up on those skills would add even more time. this, for me, is one of those questions i'm happy to leave to the experts

 

i'm curious, does the book address the idea that epidurals have made c-sections safer by reducing the need for general anesthesia? i've wondered if that benefit has ever been quantified.

Thank you for your kind comments. And I agree with you. When I have engine trouble, I bring my car to a trusted mechanic. I've got no idea how that thing works, and I don't have the years to spare that it would take for me to figure it out!

Your question regarding c-section safety is a good one. The data and the general consensus in the medical community is that yes, epidurals and spinals have made c-sections safer. One of the great advantages, of course, is that the mother can be totally awake to enjoy the wondrous moment of birth.

There is another advantage. At my hospital, we have been leaving epidurals in after c-sections to provide high-quality pain relief for 48 hours after the operation. It's a really low dose epidural, so that the new moms walk about freely, but with minimal discomfort - and they're wide awake. We think this is the best way to provide pain relief after surgery. We also use it for women who have had difficult vaginal deliveries with tissue damage.

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Quote:
  I suggest that women who want an epidural get it BEFORE the pain becomes severe. 

 This is something I am curious about.

 

I have taken lots of pain meds in my time.  I have had 7 teeth pulled, 3 root canals and countless other dental issues, requiring some form of narcotic pain relief either before or after, not to mention pain meds for afterbirth pains.  In addition, I get migraines and take meds for that, after having tried out several different options.

 

And in reading up on all the stuff I have taken (got any questions about vicoden, hydrocodone or vicoprophen?:-) )  something that is discussed quite a bit is that it's best to take the pain meds before the pain gets severe.  That pain meds work best on the pain the earlier you take them. 

 

Is this something that's true for epiduals as well?  An epidural is a different kind of pain killer, right? 

 

 There are different types of medication that can be administered in an epidural. But your thoughts are exactly right. It's definitely better to take pain relievers BEOFRE the pain begins. When's the last time time you were at the dentist and told the her/him to start drilling for a while before giving you the local? Let me guess: Never? Becuase that would be plain silly! But women in labor do that all the time. I'm not talking about those women that don't want any medications and are committed to a "natural birth." I'm talking about women who think theat they want an epidural, or are sure that they want an epidural, but they wait until the pain becomes excruciating before they get it. It makes absolutely no sense. But this is standard practice. I'm trying to explain that it shouldn't be. If you want pain relief for labor, why suffer at all? As I point out in my book, pain itself has a lot of really bad effects for the mother and the baby. In general, for various reasons, you're exactly right - it's better to tak pain meds before the pain becomes severe.



I think to some degree you're being dismissive ...and I support use of epidurals with informed consent (real, unbiased information). I for one have had a sense of guilt having had epidurals and agree that a standard "full epidural" vs a "walking epidural" are two different animals. I think laboring for some time without the epidural is beneficial in one aspect for experience but more importantly it is often hospital policy to keep a mother on a gurney/be with continuous monitoring (bp, ringer iv, 02 sat, fetal hr, possible catheterization) and of course for liability. This is not a good position to labor in for fetal descent, this doesn't help malpositioned babies get into a better position for all involved, this increases the risks for interventions.I think this practice needs some "tweaking" in order to really help reduce risks of epidurals leading to more caesareans, vacumn extraction, low forceps etc.

 

I will add a qualifier to that and say that I was very adamant in my second epidural birth (walking epidural) that I still be allowed to move around at will and whim and had none of the above problems/risks but the only reason I knew I could fight for this, and it was an argument, was because I am acutely aware of patient rights in my state having worked on the other side of things and being a particularly aggressive patient advocate.

 

 

I think more women need to know what their rights are and not be bullied by anyone and that this is really the core of the matter.I see over and over again on this board that women have grown to mistrust the medical community because of bad medical attention they have received. This to me is a huge problem for a variety of reasons not least of which childbirth where women are affraid even at a home birth to call someone in case of an emergency.

 

 I also am a vaguely offended that you would imply that women (especially on this board) can't possibly understand what statistics mean or how peer reviewed studies are conducted. This is naive on your part. There are quite a few nurses, doctors and midwives on this board let alone many other sciences (I'm neurobiology and paramedic sciences, my husband a chemical engineer). The M.D. isn't the only area of study that study these things/learn them in college and apply them in their daily working careers. Perhaps your own patients can't make rational informed choices and for that I'm truly sorry. Also I think you ignore where people might have other strengths that may or may not apply to the matter at hand. For instance in absolutely any medical emergency where there isn't a controlled enviroment I'd bet my home that I react better and more efficiently than you do..not that this applies here but hopefully you get my point.

 

 

 

It's very difficult for someone - whether a scientist, physician, physician-scientist, or (especially) a layperson to critically evaluate a study, peer-reviewed or not, in an area that is not their particular specialty. That's simply a statement of fact, not an indictment of the people on this board regardless of what their (or their spouses) educational backgrounds may be.

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I agree that it is difficult if it is not your area of specialty but this is where medical professionals need to try and give some guidance and they more often than not don't, not truly.

I think giving all of the available information including information that may conflict with your own views is important.

I don't think doctors especially are very good at being very good guides to their patients with information and too often take on a sort of authoritarian role forgetting that they are simply being hired by the patient to do their job.

 

I'm lucky that my demographic is such where medical professionals seem to be keenly aware that they are the "hired help" and frequently work with very educated patients so they generally treat their patients as equals. You'll find that the climate on this online community is more often than not the opposite experience. If you took some time to really read some of these stories around here I think any person that knows and abides by medical ethics would be horrifed by what they read and you'd see why some people will respond to your proposition with pure venom and rightly so.

The problem is far larger than whether epidurals are okay or not.

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I don't think doctors especially are very good at being very good guides to their patients with information and too often take on a sort of authoritarian role forgetting that they are simply being hired by the patient to do their job.



i'm trying to envision how the ideal OB would discuss epidurals with her patient. when i had questions with my first daughter, i simply asked my OB if she would use an epidural. she said she did not, but that was because 30 years ago, they were rather new. if she were to deliver today at her hospital, she said she would (her hospital placed thousands of epidurals per year, she said, and she knew they were very good at it). if i had wanted more information than that, i think it would have been ideal for her to point me to a book (which now she could!). but i don't think it'd work for her to suggest i hop on pub med and scan the literature myself. or take 2 hours to discuss the finer points of the literature with me herself.

 

i guess i just see the doctor's role here as giving patients the most up to date recommendations possible, and point them in the right direction if they want to know more, but not more than that. i fully expect that if i want to learn everything i can about a topic, i'll have to do that on my own. what is it that you think they should be doing differently?

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I agree that it is difficult if it is not your area of specialty but this is where medical professionals need to try and give some guidance and they more often than not don't, not truly.

I think giving all of the available information including information that may conflict with your own views is important.

I don't think doctors especially are very good at being very good guides to their patients with information and too often take on a sort of authoritarian role forgetting that they are simply being hired by the patient to do their job.

 

I'm lucky that my demographic is such where medical professionals seem to be keenly aware that they are the "hired help" and frequently work with very educated patients so they generally treat their patients as equals. You'll find that the climate on this online community is more often than not the opposite experience. If you took some time to really read some of these stories around here I think any person that knows and abides by medical ethics would be horrifed by what they read and you'd see why some people will respond to your proposition with pure venom and rightly so.

The problem is far larger than whether epidurals are okay or not.

Very interesting post of yours...first of all thank you for agreeing with me that's it's difficult for non-specialists to critically interpret clinical studies. Not everyone on this board understands this. And I agree with you that all available information should be provided, even if it conflicts with one's views. It's a shame that you think so little of doctors. And it's a shame that you view doctors as "hired help." You see, the way I was raised, and the way I was trained, and the way I view my profession couldn't be more different than "hired help." Physicians are meant to care for their patients, to be selfless and compassionate, not to allow their own prejudices to come into play. Physicians are the ultimate patient advocate, assisting them to come to grips with very serious decisions, including those involving life and death. Next time you go to one of your "hired help" doctors, if they do a good job, at least consider giving them a good tip!  I’ll bet dollars to donuts that you’ve never tipped one of your “hired help” doctors. C’mon, now, be consistent!

 

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I don't think doctors especially are very good at being very good guides to their patients with information and too often take on a sort of authoritarian role forgetting that they are simply being hired by the patient to do their job.



i'm trying to envision how the ideal OB would discuss epidurals with her patient. when i had questions with my first daughter, i simply asked my OB if she would use an epidural. she said she did not, but that was because 30 years ago, they were rather new. if she were to deliver today at her hospital, she said she would (her hospital placed thousands of epidurals per year, she said, and she knew they were very good at it). if i had wanted more information than that, i think it would have been ideal for her to point me to a book (which now she could!). but i don't think it'd work for her to suggest i hop on pub med and scan the literature myself. or take 2 hours to discuss the finer points of the literature with me herself.

 

i guess i just see the doctor's role here as giving patients the most up to date recommendations possible, and point them in the right direction if they want to know more, but not more than that. i fully expect that if i want to learn everything i can about a topic, i'll have to do that on my own. what is it that you think they should be doing differently?

I couldn't agree with you more. the reason I wrote my book is that there is no resource out there that covers the information I present. Moms-to-be (and obstetricians, midwives doulas, etc) need access to up-to-date information about state-of-the-art pain relief techniques. I have spent quite a lot of time over the course of my career following the literature. I have distilled it in my book and presented it in an easy-to-read format. I kept the references to a minimum so as not to impede the flow of the book, but there are quite a few that I have included. I suggested on this board that people can consult the studies themselves, but this was a suggestion for those people who have no intention of ever reading my book, and those people who are much to suspicious to ever trust anything that a physician tells them. Of course, the problem is that unless you are trained in a particular area, it's darn near impossible to interpret the literature accurately. The best solution to all this is to consult a number of sources that you consider to be trustworthy, and to discuss the issues with your physician or midwife (assuming you consider them to be trustworthy!).

 

I'd be very interested to hear the reactions of people on this board who have actually read my book. It would be a great jumping-off point for a (hopefully) enlightening discussion.

 

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Old 02-13-2011, 12:33 PM
 
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lol! now you know how I think! will the arrogance never stop!

 

thats not the point I was trying to make at all...at all at all

 

When I was applying to a physician's assistant program in connecticut my PCP was invaluable at helping me in my senior year get my course load finished up to be an exceptional applicant.

She also treats every member of my family for a variety of different things from my husbands epilepsy, to my thyroid cancer, to my youngest's well child check-ups. She knows I'm inquisitive and shares interesting patient stories with me without violating HIPPA (I do the same). Who by the way suggested I might want a home birth for my youngest based on her OWN horrible hospital birth experience that included a good deal of complications from an epidural! And as far as giving her a "tip" I treated and transported in her husband due to a horrible MVA.

 

My endocrinologist is very much the same in treating his patients like equals and really has some very interesting studies published in the New England Journal of Medicine on the effects of Vitamin D deficiency.

 

I have severe SPD and found a Dutch publication that goes against the grain of advice typically given in the United States for coping with it. My Obgyn practice (which is the largest in the state) requested I bring in a copy of the book so that they may order it themselves to help out other patients.

 

My point was, before you put your own projections into it, was that Dr's would be wise to remember they can be replaced and will find themselves without a viable practice if they're not careful. Here they have to worry about being sued over the slightest perceived injustice which I don't happen to agree with but it certaintly makes for a much more open line of communication between doctors and patients.

 

 

 

 

as for how a conversation should look between a doctor and a patient in regards to an epidural...the facts without bias should be layed out and this should be communicated well before labor begins in an ideal situation. The practice I have gone to this go around gave me as a new patient a new patient bag that included a good deal of information including peer reviewed studies and ranged from induction methods to hypnobabies class information.

 

Also, don't lecture me on compassion.Ive been a practicing medic for about ten years. I was also a combat medic in the war. I promise I've had to exude more compassion in those ten years then you'll ever have to in your life.

So try to do a little more comprehensive reading before you jump to assumptions please you seem a tad emotionally invested.

 

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First of all, thank you for your service to our country. We are all deeply indebted to all our heroes and heroines who defend our liberty. And I mean this with all sincerity. Civilians living a comfortable life stateside don’t give nearly enough thought to our countrymen who defend us overseas in some horrible conditions and dangerous situations. But, I don’t recall lecturing you on compassion – because I did not do any such thing. Similarly, I would suggest that you not jump to any conclusions regarding the compassion to others I have shown in my life, or comparing it to the compassion you have shown. You don’t know me, so that’s just plain silly of you. In terms of being emotionally invested, if you mean my reaction to your likening of me and my fellow physicians to “hired hands,” well yes, I do suppose you struck a chord. I take my life’s work very seriously, and don’t appreciate having it demeaned. None of this is helpful in furthering the discussion of the choices that women have for childbirth pain relief. So let’s stick to the matter at hand, OK?

' """

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Old 02-13-2011, 01:22 PM
 
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http://www.theglobeandmail.com/life/the-hot-button/epidural-guilt-debate-over-pain-meds-back-in-the-limelight/article1904419/

 

 

Quote:
He even suggests that epidurals can be used as pain relief after birth and to ease painful breastfeeding

 

 

 

Quote:
A lively debate ensued in the comments section, with Dr. Grant explaining why he sees an epidural as a “wonderful alternative” to other post-partum pain meds. For painful breastfeeding, he suggests a dose (delivered by the new mom using the technique from the study above) just before a breastfeeding session

 

 

And there went any of this man's credibility in my eyes.  I have no intention of reading a book written by a man who doesn't have a fundamental enough understanding of the breastfeeding relationship to know that, done correctly, breastfeeding should never require pain medication.  We all know that painful breastfeeding sessions can easily and quickly be resolved with a change in technique.  The Best for Babes Foundation has accurately identified this book and his belief that an epidural can (should?) be used to relieve pain associated with breastfeeding as a "booby trap."


Charlotte, midwife to some awesome women, wife to Jason, and no longer a mama to all boys S reading.gif('01), A nut.gif ('03) S lol.gif ('08) and L love.gif ('10).
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Old 02-13-2011, 01:39 PM
 
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Charmie, I would agree with you that normally breastfeeding shouldn't need pain medication and certaintly I agree that an epidural in this instance is extreme..but before making a blanket statement please look into the effects of raynaud's phenomenon/syndrome on breastfeeding.

 

You do a great disservice to the women that truly can't breastfeed with such a broad satement. I myself did not know that there were so many potential variables that are truly insurmountable.

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