Of “tramp-stamps” and epidurals

I don’t think I’ve heard of a tattoo being called a tramp-stamp  so I guess I’m a little out of the modern lingo. Which is not surprising. Specifically, it’s a decorative tattoo on the lower back. Which happens to be right about the point where an epidural would be administered.

Actually, some people say that a “true” tramp-stamp is very, very low on the back (nearly on the woman’s rear-end), while the tattoo I’m talking about really should be called a “peek-a-boo.” You learn something new every day! Anyway, I thought the term was kinda funny, and definitely left a memorable impression. It’s the sort of catchy term I could see some people embracing, to rob it of any potential or intended sting, as they gleefully thumb their nose at certain stodgy societal groups. If it is actually a pejorative term, rather than a co-opted term, and is offensive, I apologize in advance. But I think it’s funny.

Not that I’m a big fan of tattoos. I’m old-fashioned enough that I don’t particularly like them. In fact, my favorite quip about tattoos is, “Tattoos are permanent proof of temporary insanity.” It used to be that only a certain segment of society got tattoos — certainly never women! *gasp*horror* “Tattoos are for sailors and bikers, but never women!!” Tough guys who had to prove something to themselves or to the world, perhaps. But despite the stereotype of who got tattooed in the past, I don’t think that applies today. And tattoos are even fashionable, with many celebrities sporting them — big, little, visible, or hidden. But every time I think about people who get tattoos, I picture the person as an old man or woman in a nursing home, with a faded tattoo and wrinkled, shriveled skin. Because they’re going to have to live with the tattoo for the rest of their life. Like one of my friends in college who had a big black panther tattooed on her shoulder-blade. I picture the tattoo scaring the bejeebers out of some poor orderly in a nursing home fifty years from now. 🙂 I guess perhaps one of the reasons I think that, is that of the people I know who get tattoos, so many think they are young and invincible, they live for today, and think they’ll want the tattoo for the rest of their lives. But these people don’t even like to wear the same clothes two years in a row, because they like change! I also think about the woman in a Reader’s Digest funny short story, who had gotten a tattoo of a small fish or a dolphin or something on her young and firm abdomen. Then she got pregnant. And her belly, quite naturally, grew. And so did her tattoo. At one point, the nurse, midwife, or doctor asked, “That’s a nice tattoo. What is it — Shamu?” Oops! Now, I wonder what it looks like with stretch marks striping the tattoo.

So, what do tattoos and epidurals have to do with each other? Not a lot really. It seems to be a tempest in a teacup, from what I can gather, especially if the tattoo ink is dry. But some bright researchers decided to look into any possible complications from getting an epidural through tattooed skin, because they had had three women with lower-back tattoos request an epidural of them. They were all uneventful epidurals with no complications, but it got them to thinking that might be a hypothetical risk to piercing through tattoo ink and into the spinal column. Ok, that does sound like it might possibly be bad. After all, you don’t exactly want your tattoo to really get on your nerves, do you?! So, they looked through published reports that might pertain to tattoos and epidurals,  and you know what they found? Nothing. Nada. Zip. Zilch. Zero. But that didn’t stop them from publishing “what if” theories, which have led to many women being denied epidurals simply because they have a tattoo.

Now, I’m no fan of epidurals, either; but if a woman wants an epidural, then there ought to be a good reason to deny her one. And this doesn’t appear to be it! [However, getting a tattoo is not exactly a pain-free experience, so if you can manage the pain of being pierced multiple times with a needle to get the tattoo in the first place, maybe you can conjure up some of that whatever it was that got you through the tattoo procedure, to help you get through labor? Of course, I say that as someone who would probably have to be drunk or drugged in order to get tattooed, so perhaps there is no correlation between the two. I’m not scared of needles, but the thought of getting a tattoo gives me the heebie-jeebies!]

If you don’t have a tattoo yet, that may be a consideration in whether you get one or not; and if you get one, what size and kind you might get, and where exactly over your spine you want it placed. If you already have a tattoo on your back, this should be one of the earlier questions you ask your care provider (and it wouldn’t hurt to call the hospital you’re planning on using or having as a back-up, just so you know in advance), to make sure that there isn’t going to be a problem with getting an epidural, if that’s what you want. Even if you’re planning on going without an epidural, sometimes things happen to change plans, and knowing the situation in advance will give you one less curve-ball you have to deal with in the throes of labor.

Still, I wonder why research cannot be carried out on this — in rats, as an example. Or perhaps rabbits or monkeys. Maybe pigs, because they have no fur to speak of? It wouldn’t necessarily have to be a painful procedure — the animals could be anesthetized for the actual tattooing procedure. Right now, it’s just left hanging, with some anesthetists getting scared about giving women with lumbar tattoos an epidural. There are a few different intervertebral spaces that an epidural could be administered through, and it is likely that there would be an ink-free spot at one of these points, should the anesthesiologist wish to avoid the tattoo — either for fear of the ink, or for not wanting to scar the tattoo. Of course, if the tattoo is large and densely colored (say, a full-color design like a fairy, as opposed to something thin or sparsely colored, like filigreed initials), there may be no open space. At that point, as part of “informed consent” the anesthesiologist may want to inform the woman that there is no research on getting an epidural through tattoo ink, so there is a theoretical risk of some adverse reaction, and ask her if she wants to continue. Then document the consent and proceed. Sounds simple enough to me!

Post inspired by The Unnecesarean’s take on this.

~*~

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You learn something new every day — Epidural Edition

This page is a pretty informative and concise resource on epidurals, including the history of the epidural (which I had never really thought on much before), as well as a discussion of the various medicines given in an epidural (did you think there was only one?)

Did you know…

  • The first-known epidural attempt on a human was in 1901;
  • The first successful epidural was performed in Spain in 1921;
  • By 1935 single-injection lumbar epidural regional anaesthesia was introduced in the US;
  • And the continuous lumbar epidural was developed by 1946?

For more information, you can read the whole article.

Medical Risks of Epidural Anesthesia

This was an interesting paper that one of my facebook friends shared. Written by a doctor (and presumably his wife), it begins:

Epidural anesthesia has become increasingly popular for childbirth. The popular book, What to Expect when You’re Expecting, for example, portrays epidurals as perfectly safe. The risks, however, may be greatly underplayed.Note: This is a site in progress. We are interested in detailing all the risks of epidural anesthesia for childbirth. There is currently a selection bias toward the risks. We welcome all readers to send us studies about epidurals regardless of the results, so that we can continue to work toward a balanced site. Our bias is that epidurals have risks and that these risks are under-communicated to women, and that true informed consent is not given.


Epidurals and Pain Relief

For the most part, epidural analgesia does effectively relieve labor pain.1 Obstetrical anesthesiologists continue to state that epidural analgesia has other, potentially catastrophic, adverse effects but, with safe clinical practice, these problems are extremely rare. We will suggest in the material that follows that these complications are not extremely rare, and that women are not receiving adequate informed consent about what these complications are and their accompanying frequency. Nor are they being offered any serious alternatives to epidural anesthesia. Despite this, anesthesiologists such as Eberle and Norris argue that specific anaesthetic techniques … or obstetrical management can limit or eliminate these risks of epidural labour analgesia. What must be remembered for any technical procedure, is that it is studied in major academic centers where highly skilled professors supervise residents and all outcomes are monitored closely. The actual practice, however, takes place in smaller institutions by less qualified individuals so that the actual complication rates of any procedure (obstetric, cardiac, pulmonary) are always higher than what are found in studies.

I’ve read a bit of it, and will read more in the future as I have opportunity. It promises to be interesting. It would be nice if hospitals kept track of their procedures and any negative outcomes, so that the general public were actually aware of the rates. After all, they have to know these things in order to bill them; surely such information could be collected in a way to provide statistics.

The authors include a statement from the package insert of a “medication used for epidurals (manufactured by Abbott Laboratories).” I’m not totally sure which drug this was taken from — I came up with a link to bupivicaine, which had the last paragraph; but it didn’t say anything about either placentas or parturient. However, a link to xylocaine did have some of the language from the first two paragraphs. There are different drugs that could be used in epidurals (which are actually many times not true “epidurals” but are “spinals”, fwiw), so I’m not sure if I’ve got the right one, or if they’re all so similar that what goes for one generally goes for the other. Anyway:

Local anesthetics rapidly cross the placenta, and when used for epidural, caudal or pudendal anesthesia, can cause varying degrees of maternal, fetal and neonatal toxicity….Adverse reactions in the parturient, fetus and neonate involve alternations of the central nervous system, peripheral vascular tone and cardiac function….

Neurologic effects following epidural or caudal anesthesia may include spinal block of varying magnitude (including high or total spinal block); hypotension secondary to spinal block; urinary retention; fecal and urinary incontinence; loss of perineal sensation and sexual function; persistent anesthesia, paresthesia, weakness, paralysis of the lower extremities and loss of sphincter control all of which may have slow, incomplete or no recovery; headache; backache; septic meningitis; meningismus; slowing of labor; increased incidence of forceps delivery; cranial nerve palsies due to traction on nerves from loss of cerebrospinal fluid.

And people think I’m weird for not having an epidural…

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What if you can’t get an epidural?

Seriously.

I’m a proponent of natural (i.e., no drugs) birth, but I understand that not everybody shares my philosophy; and even many times when women do share this philosophy, life (or labor) throws them a curve ball, and they have to adjust.

So, picture this — you’re in labor in the hospital, and for whatever reason, you ask for an epidural — maybe you planned one since before you got pregnant, maybe the contractions just took a serious uptick in intensity and you decide that now is the time. So you push the button, the nurse comes in, you say, “I’m ready for my epidural now,” and she says, “I’m sorry, but it will probably be an hour or so before you can get one.”

What do you do?

It’s best to think about that question now, rather than while you’re in labor, when it’s too late to go to a childbirth prep class or read all those crunchy granola websites and blogs that talk about breathing and relaxation and hypnosis and whatnot.

For several plausible reasons why your epidural might be delayed, read this post. There are many others, including some that I don’t know about, and others that I have heard about but are so rare you’ve probably never heard about them and never will (unless you’re a midwife or an L&D nurse who’s heard everything). But one reason why an epidural may be delayed, even if some of the possible triage issues of that link don’t fit your particular situation, might be that you will need an IV bag of fluid before you can get an epidural. Sometimes an epidural can make your blood pressure bottom out (which isn’t good for you, and especially bad for the baby), so to prevent that, they load you up with fluid. (It doesn’t always work, and while sometimes repositioning and oxygen can keep you from having to have a C-section, other times it won’t.) It may take time to give you enough fluid, and your labor will continue during that time. This is actually the most common reason I’ve heard for a delay in receiving an epidural; but not having an anesthesiologist available (usually because s/he’s attending another patient) is the other top reason I’ve heard.

It would be very good for you to have some tricks up your sleeve to handle labor contractions, rather than just assume you can snap your fingers and have one appear. Even if you’re sure you’ll want an epidural. Even if you’re sure you’ll get an epidural. It is not unheard-of for it to take an hour from the time you ask for the epidural until it actually takes effect — little delays here and there add up — the nurse has to assess you and call for the anesthesiologist, it may take some time before s/he can actually get to your room, you’ll have to have a bag of fluid run, it takes time to set up for the epidural, and while many women describe the relief as immediate, it may take other women some time before the numbness takes effect. There’s also the less-talked-about phenomenon of a failed epidural — it either doesn’t take at all, or the coverage is only spotty, or it takes effect only on one side of your body. Then what?

This is not to scare you, but to encourage you to educate yourself. There are alternative pain relief methods — but if you don’t explore them now (and some of them need to be learned and/or practiced), you won’t have them then. Also, a doula can be of tremendous help. She may be able to help you avoid the need for an epidural in the first place, but she definitely has lots of tips and tricks to help labor be more manageable.

Miscarriage Post

I’ve never had a miscarriage, but it is a fairly common event — the estimate is that 15-20% of known pregnancies end in miscarriage (losing the baby prior to 20 weeks and/or 400 grams), with even more pregnancies ending in miscarriage unknown and unnoticed by the woman, appearing like a late and/or heavy period. This post is one woman’s experience with a miscarriage. Although I’ve known many women who had miscarriages, I’ve never heard quite this description, on an emotional, mental, physical, and hormonal level.

It cost HOW MUCH??

Most of the birth blogs I read have talked about one or both of the birth-related articles that recently appeared in the LA Times and Time magazine. But Knitted in the Womb talked about one I hadn’t seen — from the Wall Street Journal, which talked about the hospital bill a woman received for her uncomplicated vaginal birth: $36,625! Although the total cost was negotiated down by the insurance company (about half off), she still had to pay a percentage of the bill, and had the nasty surprise of finding out that in addition to her annual deductible, her newborn had his own deductible to meet! [If you haven’t read the other articles, Knitted in the Womb has the links on her blog page.]

Not having had a hospital birth, it was definitely a curiosity to me to see certain aspects of this as-yet-unseen type of bill. It was a rude shock, but important for everyone to know, because even if you believe you don’t pay out of pocket, you really do, because all costs the insurance company incurs are passed along to their customers in one form or another. You’re paying for your coworker’s C-section. Fun, huh? [Oh, and don’t expect nationalized health care to improve matters — it will have all the (in)efficiency of Medicare and Medicaid, but on steroids.]

Back to the article — she writes that she requested an itemized statement to make sure she wasn’t billed for services she did not actually receive, and found that the sterile epidural tray cost $530.29.  Then writes,

An “Anes-cat 1-basic Outlying Area” was billed at $2,152.55. (I was told this was the cost of the hospital’s resources related to the epidural.) These items were in addition to the separate anesthesiologist’s charge of $1,530 for giving the epidural. Even though the pain-killing epidural shot felt priceless during my 20 hours of labor, I was amazed that its total cost could run so high. [In case you haven’t added that up, it’s over $4,000 for an epidural. And people think that childbirth classes and a doula, which can help you avoid needing an epidural, are expensive! The woman had to pay 15% of charges, so if these charges were the final charges her insurance company agreed to, then that’s about $630, which could cover both childbirth classes and a doula in many areas of the country.]

… the hospital listed a price of $2,382.92 for my recovery, when I hadn’t had a Caesarean section. It turned out the charge was for the 90 minutes I spent in the birthing room after my delivery. I recalled lying exhausted there while a kind nurse checked my vitals and cleaned me up. Important help, for sure, but was it really worth that much money? [This cost of recovery is nearly as much as I paid for my whole birth “package” with my midwives each pregnancy. The prenatal visits were anywhere from 30-90 minutes long, plus they came to my house for the birth and stayed during labor and for a few hours afterwards checking on me and making sure everything was cleaned up. Oh, and it included a labor doula, too!]

Interesting, to be sure. To those of you who have had hospital births, did you know these charges (or anything like it) beforehand? If you have insurance, did you ever see these kinds of bills, or only your out-of-pocket costs (whether home or hospital birth)? If you work in a hospital, are you aware of how much people are billed for services in your hospital, or is that “just something people in billing deal with”?

Informed Consent for Anesthesia

Regarding the role of the health care professional, the American Medical Association defines informed consent in the following way:

Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. In the communications process the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with [the] patient:

(1) The patient’s diagnosis, if known;

(2) The nature and purpose of a proposed treatment or procedure;

(3) The risks and benefits of a proposed treatment or procedure;

(4) Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);

(5) The risks and benefits of the alternative treatment or procedure; and

(6) The risks and benefits of not receiving or undergoing a treatment or procedure.

In turn, [the] patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.

Do you feel like you have truly given your informed consent when it comes to procedures that were performed on you during pregnancy, labor, birth, or postpartum? Not just anesthesia, but for everything  — like an IV, being forced to stay in bed, or deprived of food and water, or having continuous fetal monitoring.

The above italicized portion was from Nursing Birth blog. Click here to read the rest of the very informative post, including an actual hospital informed consent form which you can read right now, instead of waiting until you are deep in labor.