[mothernatureskathy]

Does anyone have any suggestions for my clients who must have cesareans and still want to be very alert to breast feed afterwards? In this hospital in Florida the doctors like to use spinals and not epidurals for scheduled c/s. They feel it works better for some reason I do not understand. But after the birth they want to give the mothers a large dose of narcotics for pain control. One mother who has a bad reaction to narcotics had to insist that she get Tramadol. The doctor said it could cause some bleeding at the incision site but agreed. Other mothers who he insists on giving the narcotics fall asleep shortly after the surgery and they are not alert for nursing. When we asked for a 24 hour spinal they first said there was no such thing and then they said it was not safe because the mother would need much more supervision for the 24 hours after surgery. I would think a drugged mother would need a lot of supervision too. It seems they use these 24 hour epidurals regularly in some places. I looked it up on line and it seems pretty common place. My question is why would a doctor use a spinal instead of an epidural and why do some use 24 hour epidurals and spinals and others won't?

 

[snowmom5]

I'm not a birth professional, but it is my understanding that a spinal gives more certain pain relief than an epidural for surgery.

I had a spinal with my c-section several years ago. I only had ibuprofen afterward but that was a mistake - I didn't realize there was stronger stuff. I don't like vicodin (makes me dizzy). After my last vbac, the afterpains were so bad that I had percocet - just one was enough (I have to use that sparingly too or I'll get dizzy - but it did the trick - I could not take ibuprofen due to starting coumadin). These types of drugs - ibuprofen, vicodin, percocet - do not exactly require anywhere near the supervision that continuing spinal or epidural anesthesia would require, as far as I can tell - because with an epidural the mom cannot get out of bed to pick up her baby or use the bathroom.

Personally, to me the idea of a 24 hour epidural sounds horrible. Getting up and around as soon as possible - usually after 12 hours - is important. (ugh, the gas pains!) If the moms are too drugged up, maybe they're on too high a dose of whatever medicine it is? Couldn't they ask for a lower dose? I think that would be a better alternative than a continuous epidural, especially since the epidural would have to come to an end eventually, and they'll still have to get up eventually, and they'll still have pain.

just my two non-birth-professional cents

(also, FWIW, I vaguely recall sleeping a lot in the afternoon after my section - I still nursed but the surgery, combined with not having slept much in anticipation, really wiped me out)

 

[Hallielynn01]

Which Kathy in PPark is this?? Welcome to Mothering.com!

That was my understanding too, about the reasons for a spinal vs epi for a section. as far as better pain relief

I also find that the post-op period varies with moms, depending on what they went through before. I've had moms who birthed by ceserean with no labor, and they were quite alert and ready to nurse, and others, who labored for 2 days, then ended up with a ceserean and were just plmub exausted and others who were wore out, groggy from drugs, but able to start nursing with a little help.

I think a 24 hour spinal/epi would be restrictive for the mother as well as requiring far more monitoring (blood pressures etc, I imagine the need would be the same after birth as during birth for those issues, but I'm only speculating)

 

[PTmorgan]

Not a birth professional, but I have something to add:

In my area here in Colorado they use a long-acting narcotic in the spinal called Duramorph. It really helps a lot with post-op pain control without having a lot of grogginess.

I work in the hospital as a physical therapist, and am one of the first people to get patients out of bed after surgery. I've found that Duramorph works pretty well - not completely, of course. I've also heard that spinals tend to give more complete coverage for anesthesia. Also, leaving the catheter in the spine leaves more room for complications.

On a personal note, I had an emergency C-section with a spinal. I refused all narcotics, even the Duramorph, because I stop breathing with even a small dose. I was alert the whole time, and DS was nursing for the whole time I was in the recovery room. I asked for Toradol for pain control instead. It worked pretty well. MDs are hesitant to use it because it's a very strong anti-inflammatory and can cause bleeding (stomach ulcers, etc). They would only give me three doses. However, I needed something besides Tylenol and Advil!

I wonder if they use Duramorph where you live?

 

[rainashine]

My c-section was with an epidural but I had a kidney surgery years ago with a spinal (general makes me extremely ill) and I gotta say, the spinal was fabulous for pain relief! I evidently got some serious meds after my epidural c-section too and was soooo groggy. I did get to breastfeed in recovery but I needed help holding dd and when they brought her to me the following day (born at 1:30am) the only reason I knew she was mine was because I remembered three little baby acne spots on her cheek from where dh held her up to me while they stiched me back up. Everything from recovery was just a blur. Why do they do that!?!? Why can't they figure out some pain relief that doesn't take away the memories and the chance for memories?

 

[cileag]

I don't usually find that the spinal is what makes women groggy. Often during the c/s women are given meds (often without a lot of information) for various things like nausea/vomiting, tachycardia, hypotension etc. I find that those are the meds that really "gork" moms out. Anti-nausea meds especially.

The duramorph I support quite a bit---my experience with it is similar to PTMorgan, a much quicker recovery time with greater ease of movement. An epidural for a c/s actually takes longer to "set" and you have to inject the mother with greater amounts of the narcotic/numbing infusion to get the site numb enough for surgery.

So for scheduled c/s, I find that most moms are very alert afterwards. I give toradol for pain immediately after the c/s (does not make you drowsy), and then use an iv narcotic about 20% of the time at the mother's request if she has breakthrough pain. For an unschedule c/s, it's often just the stress of labor etc that makes mom so dramatically tired. After a vaginal birth, I see it too, but the mother's endorphin alert time coincides with being with baby. For a c/s, she's getting stitched up and transferred etc and so by the time she gets to her room that first hour is mostly over and she's getting drowsy.

I hope that sheds some light on things.

 

[KatWrangler]

Not a birth professional here....but a Mom with 3 CS.

With my son I was induced, labored for 18 hours and ended up with a CS. I did have an epidural during the labor and the CS. I was very groggy and ended up dozing off.

I did have problems BF him. In retrospect it was a combination of problems.

Oh and I had him in a Denver area hospital.

With DD1 I had in Southern Cal. It was a scheduled CS and I had a spinal. It was awesome! I was wide awake. Immediately after the CS my husband, DD1 and I were taken to a private recovery room with our recovery nurse. My daughter was nursing less than an hour after I had her. Nursed to 21 months of age.

With DD2 I had her in Bozeman, MT. Again a scheduled CS and I had a spinal. Awesome again! We were taken to recovery and she was nursing within 45 minutes after I had her. They even brought in the LC to make sure I could get her latched.

With all my kids I took breastfeeding safe pain meds with no problems. None to me and none to the kids.

In regards to the 24 hour epi. My daughter had another spinal cord de-tethering Feb 2008. They did do an epi that was left in place for pain relief. Thats the first time I have heard of them doing this.

 

[dewi]

I am a birth professional!

Your client has patients rights.
If there is no clinical reason, doctors preference is NOT a good enough reason to not follow a patients wishes!

Some women choose not to have follow up pain medication, it is the women who gets to decide, to have as much or as little as she needs or wants, NOT the doctor! Pain management is based on an individual.

I personally did not need pain medication beyond tylenol, others need morphine because it's so intolerable. So there is a huge range of pain management available after a cesarean, and it cannot be one size fit all.

It is her choice, not her doctors !

 

[mothernatureskathy]

I appreciate all the suggestions for my question about the 24 hour epidural. I think however I did not explain myself correctly, I did not mean to imply that the mother would have an epidural for 24 hours that is just the name of the epidural that has long acting (up to 24 hours) of pain relief after it is turned off. It must have some Morphine in it like Duramorph etc. When a couple of my clients asked to have an epidural like this the doctors were very resistant and refused. I wondered why it is so common place in some places and so unused in others. To go through an entire surgery awake and then be knocked out with heavy medications like Delauded (spelling?) afterwards it seems a shame. I guess my question should be what can parents do to convince their doctors that they are informed such a tool exists and they would like to have it at their disposal?

 

[FernG]

I'm not a birth or a medical professional, but I am from a family of advanced practice nurses and doctors. In my family, the common opinion is that anesthesiologists have their preferred methods and they do not like to deviate from their plan. Some will be "yes men" to the patients and then do their own thing anyway.

I think you would need to meet with the anesthetist ahead of time and have a plan of care established.

 

[cricketsmomma]

Not a pro either, just a c/s mama...
I had a spinal. My c/s did not follow labor, though it wasn't scheduled either, long story. My doc explained that they use a spinal because it's quick on, quick off. It worked completely (as in no feeling from about the chin down) in maybe 5 minutes. I was able to feel/move my legs an hour after surgery, and was walking to the potty unassisted in maybe 10 hours (the next morning as soon as the catheter was out). The drawback was that my bp dropped super-low during surgery, but I hear that happens with epis too.
I don't know what the drug was - I know some kind of morphine was involved, but the doc was right, it was fast acting and fast off. I was super alert after surgery (groggy during, probably because of the bp) - actually I was so wired that my surgery was at 8 p.m. and I didn't sleep til lunch the next day. The nursing challenge was from the percocet they wanted me to take after. Made for a dopey baby. I only took it once, then no more meds, and she nursed just fine after that... for 2 years.
HTH

 

[Lovemy3babies]

I hate csections... I have had 3...

But I LOVE DURAMORPH lol. I didnt have it with my first 2, and didnt know I was going to have it with my 3rd until the next day I hopped out of bed and went potty and dressed myself. My friend looked at me and was like "Umm why can you do that?" having had 2 sections herself, she knew it wasnt normal. The nurse came in and I asked why I could move around and it didnt hurt and she told us duramorph. It was amazing. Mine lasted about 48 hours. My csection was emegency so the only thing I can figure is they did that for a reason and it was extra strong because I could do ANYTHING, even slept ON MY STOMACH. It was awesome. My friend ended up with another csection also and it didnt do for her what it did for me, not sure why!

 

[mamato3cherubs]

I am not familiar with the exact thing you are refering too. But do know that limiting mobility after surgery is not a good idea. I do understand where you are coming from reguarding pain management afterward. But if this long acting medication, leaves her unable to get up for 24 hours after, I would be worried about getting everything in the system moving again, including circulation. This would put the mother at a higher risk for blood clots as well as make it more difficult to get the digestive tract moving again.

There are reasons they get surgery patient back on thier feet. As I said, I dont know if what you are refering too would leave the mama immobile, but that would be my concern for sure.

 

[shanniesue2]

I really think the outcome is more going to depend on the combination of individual circumstances that what specific form of anesthesia they use. I think that some women are going to react better to one drug than another. And some anesthesiologists will prefer one combination of pain meds and anesthesia drugs to another. And some women are going to react to major surgery differently than others. And some doctors are going to be skillful than others. Then you have to factor in the reason for the c/s, whether or not the woman labored. If it was a difficult or long labor. Or if some kind of emergency took place.

A friend of mine, for example, had a c/s about 7 months before I did. Basically for failure to progress (after only 10 hours

). She had a longer healing time than I did. And at one point I remember her saying that she still had pain up to a year later. I don't know what kind of anesthesia and pain meds she had. But in the hospital, she did pretty well. My c/s was also for failure to progress (after 31 hours). I had a spinal block and then the anesthesioligist asked if I wanted something to help me relax. I wish I'd said no because it did make me too loopy to nurse my baby when he needed it at first (this wore off after a couple of hours). But I never had much pain at the incision site. I had horrendous retained gas though. Even breathing was excruciatingly painful. When I went home, I took my pain meds and they did a decent job. I was mostly just exhausted from the whole ordeal. And There were times that my incision was a little sensitive, but I would say that my healing process was actually quite smooth. And even though, I had a little bit of a rocky start to BFing (we used a nipple shield for about 6 weeks). But we are still BFing 13 1/2 months later....

Anyway, doctors have a reason for using the techniques they do and anesthesiologists have a reason for using the drugs they do. And I honestly believe that they make these decisions out of a desire to make the best possible choices. I don't believe they are sitting their thinking, "this is most convenient for me and I know it's going to make things hard on the mother and baby." So, rather than prescribing to them which form of anesthesia you think they should use, it might be more beneficial to have your clients meet with them and explain the kind of outcome they'd like to have. Tell the doctors, "I want effective pain control that won't prevent me from physically being able to respond to or nurse my baby. Nursing my baby within an hour (or whatever time frame) of the surgery is VERY IMPORTANT to me and to the health and well being of my baby." Then let the anesthesiologist make suggestions for what the best combination of anesthesia and pain meds is to acheive that goal. And then just make sure that they have good support for BFing following the surgery. Make sure they make an appt with the hospital's LC ahead of time... or that they schedule a LLL leader to be there to help them.

But I would definitely agree with PPs that being able to get up and walk after the surgery is going to be vital. I know that, for me, walking was the only thing that made the pain from the retained gas even remotely bearable (and even then the pain was horrible--and the drugs they were giving me for pain didn't even come close to touching it).

 

[AlexisT]

I had the narcotics (diamorphine in my epidural as per NHS recommendations). There is evidence showing that it promotes quicker healing and shortens reliance on pain medication, and I would ask for it again if I needed a repeat. Overall, I was very happy with the pain management I had.

Honestly - I would much rather have the modern approach to pain control (that it's a right, that patients should not be forced to suffer) than what I have seen when doctors and nurses stint on the painkillers. Pain does not promote healing from major surgery.

mamato3cherubs, I don't think most immediately-post-CS patients can get up narcotics or not. If anything the narcotics make you get up sooner. I was told to get up and go to the toilet on my own 24 hours post-section. (Due to some complications I had a catheter for 18 hours post-op, so I couldn't have gotten up before that had I even wanted to.) I did it, but I could only shuffle. The narcotics didn't make me unfit to walk; surgery did.

Generally speaking they like spinals for CS because they're easier to administer and don't have to worry about top-ups, but every anesthesiologist has his quirks. Mine preferred combined spinal-epidural which is normally what's used for labor. (And in the end he couldn't do the spinal part and I had a regular epidural.) I still have no idea why he chose that. I didn't have issues with the density of the block, which some women report for epidural.

 

[mamato3cherubs]

Quote:

Originally Posted by AlexisT I had the narcotics (diamorphine in my epidural as per NHS recommendations). mamato3cherubs, I don't think most immediately-post-CS patients can get up narcotics or not. If anything the narcotics make you get up sooner. I was told to get up and go to the toilet on my own 24 hours post-section. (Due to some complications I had a catheter for 18 hours post-op, so I couldn't have gotten up before that had I even wanted to.) I did it, but I could only shuffle. The narcotics didn't make me unfit to walk; surgery did. .

I completely understand this, my point with it I guess is that if you start with something that will leave you immobile, you never know if you could have been mobile without it. If you dont do anything ahead of time to prevent mobility then you may be able to be mobile, as many women are after c/s or other abdominal surgery, or as you said, you may not. I know how bad the pain of abdominal surgery can be, although I have never had to go through the experience of a c/s which would be made that much worse by everything else that can play into the situation. But I do know that my dr would not have been one bit happy if I was still not out of bed after 24 hours, and neither would I.