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.

Anesthesia and future learning disabilities…

Ok, I just read about this study, and haven’t really “ruminated” on it, which I normally do, so I’m just shooting from the hip with this. Basically, researchers went back and reviewed birth records of children born in one locality in Minnesota from 1976-1982, to see if they were born vaginally or by C-section, and if by C-section, then with the mom under regional or general anesthesia. Then, they looked at the children to see if they had any learning disabilities during school…

I’d like to read the entire article, and not just the abstract. I wonder if they controlled for enough stuff in this study. I was born in another state during the time period of this study, and my mom was knocked out during a routine vaginal birth; I assume I was dragged out by the head with forceps. Obviously, I have no learning disability — or if I do, imagine just how brilliant I would have been, if I hadn’t been born that way! ;-P But just because a woman gave birth vaginally does not mean she did not have general anesthesia nor regional anesthesia. Was this controlled for? It appears that all vaginal births were lumped into one group, regardless of whether or not a woman had drugs either for pain (such as an epidural, pudendal block, IV or IM or SQ narcotics or other drugs), or to speed up her labor (pitocin); it also is not noted in the abstract whether there were any forceps or vacuum (if applicable at the time) births; nor was the neonates’ condition noted (such as Apgars, NICU admittance, etc.).

Some women may have gotten general anesthesia, and were “under” a lot longer with their babies inside of them, during a vaginal birth than during a C-section — a typical C-section takes an hour, but the actual time from giving drugs to getting the baby out is in the neighborhood of 5-15 minutes — quicker if an emergency, slower if not. I recently read a nurse’s first experience with attending a C-section with general anesthesia, and she said the doctors worked in double-quick time, because they wanted the baby out as quickly as possible, so it wouldn’t have negative effects from the drugs given to the mother. I don’t know how long women were usually knocked out for either vaginal or C-section births, but this would seem to be  a relevant factor. After all, sometimes a little of something might not be bad, but a lot of it could be. Drugs definitely fall into this category.

I find it interesting that “drugs don’t harm the baby” yet somehow babies whose mothers were given regional anesthesia for C-sections had fewer LDs than mothers given general anesthesia for the same operation. It would seem, then, that general anesthesia was more harmful to babies than regional anesthesia. Were there *any* mothers not given *any* drugs? These should have been the control, not just “vaginal birth” which can come with a plethora of drugs and other interventions.

I first read about the study on “Mommy Myth Busters,” and they look at this from another angle, and include more information, including that “The team is investigating whether use of an epidural on a mother during natural labor has similar effects on the incidence of learning disabilities in children as a C-section with an epidural.” So, this research doesn’t look at women who give birth vaginally or by C-section with an epidural. If I remember correctly, the drugs and procedures used 30 years ago were quite different from what is the current norm today, with much of the then-standard practices going the way of pubic shaves and 3-H enemas (high, hot, and a helluva lot).

So, I think this research may be important, but it is probably going to be pretty well mangled by the press, leading women to think that their babies may even be better off to have a C-section with an epidural than to have them vaginally without drugs. When that wasn’t what was even looked at in the study. We’re looking back through time at what was perhaps standard operating procedure three decades ago, which is quite a bit different from current norms.

Allow me to say that this myth may not be quite as “busted” as one might think from reading the popular press. I remain skeptical. Perhaps time will tell…

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.

Doula segment on the Today Show

If you didn’t see it when it aired originally, go check it out — pretty good! I didn’t particularly like how they had the cost of a doula ($200-$800), non-refundable by most insurance companies, sounding like such a big negative. I know it’s a big chunk of change out of pocket, but it is important to realize what you get for your money. In fact, if a doula can help you avoid unnecessary interventions (like an epidural or a C-section), you may easily recoup your cost by having lower out-of-pocket costs from your hospital stay (unless you have a set price regardless of what happens; but most people pay a percentage of all costs), and as I pointed out in this recent post, a percentage of all costs associated with an epidural and/or a C-section may easily be more than the cost of a doula which can help avoid all that.