how common is it for the anesthesiologist to refuse to give an epidural?

[Anonymous]

They do have other pain management techniques that are available depending on the hospital. An epidural is not a right.

[Anonymous]

The first anesthesiologist I saw while in labor also said no epidural for medical reasons. I was having back labor and an induction and the midwives got the head anesthesiologist to come in for a second opinion, who did the epidural himself. However, as much as my labor would have sucked and probably ended in a csection without pain relief, I would much rather have a doctor make a judgment call against doing a procedure that s/he doesn't feel comfortable with. It sucks, I really truly get it, but it is not medically necessary to have an epidural for pain relief.

[Anonymous]

Anonymous wrote:I used to listen to the Birth Hour and there would occasionally be someone on who would note they couldn't have an epidural, but they usually knew that in advance. Seems odd that this wasn't communicated to your friend until after the induction was started when they could have strategized to avoid her being in so much pain. That sounds like bad coordination/communication on the part of the medical team. Epidural analgesia can have serious side effects even among totally healthy people so I have to think it's not unheard of to risk someone out.

CRNA here from above. This is somewhat rare. Usually complications/conditions that take epidurals off the table are discussed during pregnancy. However it could be that the anesthesiologist on call that night was a little more conservative and didn't feel comfortable doing it despite her getting epidurals in the past. It could be be a condition that tends to worsen with each pregnancy so maybe its something that would get an OK the first time around but not for the 2nd or 3rd birth. Its really hard to say. I have made a few calls that are contested. I immediately call my boss who always backs us up. I had one woman call the head of the hospital (as in the CEO…not even a DR) who then called me and apologized but felt like he "had to try." I am a mom, I am a care provider, I want you to be comfortable but I mostly want you to be alive. As someone who has given birth with and without epidural I realize how much relief it can provide BUT that relief has to be compared to possible risks and I can't make you a good candidate because a.) you know "people" b.) you have had one before c.) Dr. ABC and Dr. XYZ said it would be fine.

[Anonymous]

I don't disagree with what anyone is saying but no one is talking about the fact that giving birth is more than "uncomfortable." It's not like asking someone to just tolerate a headache without Advil. For many women, the pain is completely unbearable, hence why they want and get an epidural.

Being denied an epidural in the throes of labor if you are not prepared or planning on an unmedicated delivery I would imagine was probably very traumatizing for your friend. How is she handling her feelings? It is a real shame that her OB did not recognize this issue before so a plan could have been put into place in advance and that responsibility is really on the OB if he/she was aware of the condition of your friend.

The WHO recognizes that "Many women appreciate some form of pain relief in labour and would like a choice of options."

Was she given any other options for pain relief? The new WHO Intrapartum Guidelines state:

"Parenteral opioids, such as fentanyl, diamorphine and pethidine, are recommended options for
healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences."

Did they offer her anything like that?

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1

[Anonymous]

Anonymous wrote:I don't disagree with what anyone is saying but no one is talking about the fact that giving birth is more than "uncomfortable." It's not like asking someone to just tolerate a headache without Advil. For many women, the pain is completely unbearable, hence why they want and get an epidural.

Being denied an epidural in the throes of labor if you are not prepared or planning on an unmedicated delivery I would imagine was probably very traumatizing for your friend. How is she handling her feelings? It is a real shame that her OB did not recognize this issue before so a plan could have been put into place in advance and that responsibility is really on the OB if he/she was aware of the condition of your friend.

The WHO recognizes that "Many women appreciate some form of pain relief in labour and would like a choice of options."

Was she given any other options for pain relief? The new WHO Intrapartum Guidelines state:

"Parenteral opioids, such as fentanyl, diamorphine and pethidine, are recommended options for
healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences."

Did they offer her anything like that?

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1

I'm sorry but all women should be prepared with pain free birthing techniques. I know A LOT of women who were unable to get epidurals because their labor progressed too fast or they couldn't get to the hospital in time. You should be prepared for a worst case scenario.

It's not like they're performing a csection on you without pain medicine.

In most 1st world countries women labor with nitrous oxide instead of epidurals. Many hospitals around here are now offering that as an option.

[Anonymous]

I have 3 kids - I had the first with an epidural and the other two without.
With #2, I asked for an epidural and they had to run a blood test and give me fluids before I could get it. I ended up having the baby before all of that could be done. But yes, the fact that I recall having to do the blood test first leads me to believe that the anesthesiologist could have “not liked” what the blood tests showed and have decided I couldn’t get one, though I believe that would be rare.

[Anonymous]

I had HELLP syndrome with #1 and got a range of 50K when anesthesiologists were asked what their absolute platelet cutoff for a spinal was. (I was going into an emergency c-section, so the alternative was GA not just unmedicated birth.) The hospital said the cutoff for residents/fellows to perform with assistance was 100K and that attendings had their own cutoffs between 50K and 100K. (The platelet test is performed up to an hour the c-section and in the case of HELLP, platelets often keep falling rapidly, so some wiggle room is built in. Apparently in a stable platelets scenario, some doctors will go as low as 25K.) Anyway, the on-call doc had a cut off of 75K and it was a hairsbreath from being an issue, because my platelets came back at 75K on the dot. If they'd come back at between 50K and 75K, we were going to try to make a stink, because GA is bad for the baby. In any case, luckily we didn't have to and the blood tests at delivery (about 35 minutes post-the original blood test in my case) later came back at 57K, so they were falling fast and I got really lucky to avoid a fight/GA.

[Anonymous]

Anonymous wrote:There are some conditions (I have a mild case of spinal bifida) that make anesthesiologists nervous. There is an increased risk for the patient and an increased risk for the anesthesiologist. The risk tolerance level of every doctor is different. Maybe she got a conservative doctor who wasn’t comfortable. You normally get the rotating anesthesiologist so not like they can go down to the OR and find some others.

I have a curvy spine and was warned to parepare for an unmedicated birth in case the epi could not be done, or didn't work. It didn't work all the way so I had an unmedicated birth the second time, which wasn't that bad but it also wasn't induced.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I don't disagree with what anyone is saying but no one is talking about the fact that giving birth is more than "uncomfortable." It's not like asking someone to just tolerate a headache without Advil. For many women, the pain is completely unbearable, hence why they want and get an epidural.

Being denied an epidural in the throes of labor if you are not prepared or planning on an unmedicated delivery I would imagine was probably very traumatizing for your friend. How is she handling her feelings? It is a real shame that her OB did not recognize this issue before so a plan could have been put into place in advance and that responsibility is really on the OB if he/she was aware of the condition of your friend.

The WHO recognizes that "Many women appreciate some form of pain relief in labour and would like a choice of options."

Was she given any other options for pain relief? The new WHO Intrapartum Guidelines state:

"Parenteral opioids, such as fentanyl, diamorphine and pethidine, are recommended options for
healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences."

Did they offer her anything like that?

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1

I'm sorry but all women should be prepared with pain free birthing techniques. I know A LOT of women who were unable to get epidurals because their labor progressed too fast or they couldn't get to the hospital in time. You should be prepared for a worst case scenario.

It's not like they're performing a csection on you without pain medicine.

In most 1st world countries women labor with nitrous oxide instead of epidurals. Many hospitals around here are now offering that as an option.

As much as no one wants to hear it, Medication durin/ at birth is a comfort measure, not a medical necessity.

Depending on the medical reason for refusal of the epidural, opiates may also not have been an option OR the hospital may have no protocol for using them.

It goes against the grain to say so, but no woman should rely on the fact that she can and will get pain relief during labour. There are a lot of medical reasons not to.

[Anonymous]

Anonymous wrote:

Anonymous wrote:There are some conditions (I have a mild case of spinal bifida) that make anesthesiologists nervous. There is an increased risk for the patient and an increased risk for the anesthesiologist. The risk tolerance level of every doctor is different. Maybe she got a conservative doctor who wasn’t comfortable. You normally get the rotating anesthesiologist so not like they can go down to the OR and find some others.

I have a curvy spine and was warned to parepare for an unmedicated birth in case the epi could not be done, or didn't work. It didn't work all the way so I had an unmedicated birth the second time, which wasn't that bad but it also wasn't induced.

I have a curved spine, which I didn’t know until they were administering a spinal in the OR for my c section. You just don’t know. As it was, they had to adjust the dosage and placement so much that I could not feel or move one of my legs until the next morning. I’m assuming had I not already been in the OR, it may have affected any other pain control measures in the delivery room.

[Anonymous]

Anonymous wrote:I don't disagree with what anyone is saying but no one is talking about the fact that giving birth is more than "uncomfortable." It's not like asking someone to just tolerate a headache without Advil. For many women, the pain is completely unbearable, hence why they want and get an epidural.

Being denied an epidural in the throes of labor if you are not prepared or planning on an unmedicated delivery I would imagine was probably very traumatizing for your friend. How is she handling her feelings? It is a real shame that her OB did not recognize this issue before so a plan could have been put into place in advance and that responsibility is really on the OB if he/she was aware of the condition of your friend.

The WHO recognizes that "Many women appreciate some form of pain relief in labour and would like a choice of options."

Was she given any other options for pain relief? The new WHO Intrapartum Guidelines state:

"Parenteral opioids, such as fentanyl, diamorphine and pethidine, are recommended options for
healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences."

Did they offer her anything like that?

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1

15:00 here. It was completely unbearable for me. I had back labor and maxed out Pitocin. It was BAD. I still wouldn't argue with a doctor who made a medical judgment. I'm eternally grateful that the midwives advocated for me, but if they hadn't, then that would have been that and I probably would have ended up with a csection. As others have said, you ALWAYS have to be prepared for an unmedicated delivery. What if the epidural fails or only works on one side? What if your labor is too fast? What if the anesthesiologist is tied up with an emergency? It's shit luck to have things go wrong in labor, but if you want to have some semblance of a positive birth experience, then you have to reconcile yourself to rolling with the punches.

[Anonymous]

Anonymous wrote:

Anonymous wrote:If something goes wrong with the epidural, the blame would be on the anesthesiologist and he/she would be sued. The patient cannot overrule the doctor’s decision on this.

This. I really wish people would realize this has nothing to do with your OB…he/she has no say in this matter. I am a CrNA and I see these situations often. The patient is mad that the OB "won't go to bat" for the patient but thats not how it works. Also our risk assessment is basically the most important part of our jobs please dont pressure me to lessen my standards.

I am not sure I totally agree. Not that the OB should try and override the Anesthesiologist but that the OB should have flagged this as an issue before inducing.

I have a friend with well controlled epilepsy who was induced. Her neuro was concerned about pain triggering a seizure and she had a epidural placed before the pitocin started. As a side benefit, If she has arrived at the hospital to find an anesthesiologist with concerns there would have been time for the CrNA to talk to the neuro or come up with a new plan because they could delay the pitocin. By waiting until the induction was underway, they lost that chance.

[Anonymous]

Anonymous wrote:I had HELLP syndrome with #1 and got a range of 50K when anesthesiologists were asked what their absolute platelet cutoff for a spinal was. (I was going into an emergency c-section, so the alternative was GA not just unmedicated birth.) The hospital said the cutoff for residents/fellows to perform with assistance was 100K and that attendings had their own cutoffs between 50K and 100K. (The platelet test is performed up to an hour the c-section and in the case of HELLP, platelets often keep falling rapidly, so some wiggle room is built in. Apparently in a stable platelets scenario, some doctors will go as low as 25K.) Anyway, the on-call doc had a cut off of 75K and it was a hairsbreath from being an issue, because my platelets came back at 75K on the dot. If they'd come back at between 50K and 75K, we were going to try to make a stink, because GA is bad for the baby. In any case, luckily we didn't have to and the blood tests at delivery (about 35 minutes post-the original blood test in my case) later came back at 57K, so they were falling fast and I got really lucky to avoid a fight/GA.

Platelets can be a real issue. The risk of epidural with platelets too low is that you continue bleeding and put pressure on the spinal cord, causing potentially permanent paralysis.

[Anonymous]

Anonymous wrote:

Anonymous wrote:My friend recently had a baby in DC, and the anesthesiologist refuse to give her an epidural because of medical reasons that she feels were not adequate (I don't want to go into too much detail). She had epidurals for her previous births.

My friend's OB did not agree with the anesthesiologist, but the OB couldn't change his mind, so my friend labored and birthed with no pain medication. She was induced, which is apparently more painful that childbirth without induction.

I am angry on her behalf because I feel like if my friend and her husband (having heard about the concerns of the anesthesiologist) still wanted an epidural for her, they should have been allowed to make that choice.

How common is this refusal? I have heard about folks who waited too long to get an epidural, so they couldn't get one in time, but not about the anesthesiologist just refusing to give one.

And would they agree not to sue the anesthesiologist if something went wrong? Even if they signed something, I bet they'd still try. Not to mention the anesthesiologist having to live with the guilt of injuring or filling a patient.

The medical reason matters, too. Just because she had epidurals before doesn't mean that there wasn't a reason not to administer one this time.

Such as the platelets issue above. Honestly, I would find it hard to believe that a new mother left paralyzed from the waist down because of an epidural that she did not need and was risky (but she wanted) would say, "well, my fault for not realizing I might regret it. Not going to sue the anesthesiologist or the hospital."

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I don't disagree with what anyone is saying but no one is talking about the fact that giving birth is more than "uncomfortable." It's not like asking someone to just tolerate a headache without Advil. For many women, the pain is completely unbearable, hence why they want and get an epidural.

Being denied an epidural in the throes of labor if you are not prepared or planning on an unmedicated delivery I would imagine was probably very traumatizing for your friend. How is she handling her feelings? It is a real shame that her OB did not recognize this issue before so a plan could have been put into place in advance and that responsibility is really on the OB if he/she was aware of the condition of your friend.

The WHO recognizes that "Many women appreciate some form of pain relief in labour and would like a choice of options."

Was she given any other options for pain relief? The new WHO Intrapartum Guidelines state:

"Parenteral opioids, such as fentanyl, diamorphine and pethidine, are recommended options for
healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences."

Did they offer her anything like that?

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf?sequence=1

I'm sorry but all women should be prepared with pain free birthing techniques. I know A LOT of women who were unable to get epidurals because their labor progressed too fast or they couldn't get to the hospital in time. You should be prepared for a worst case scenario.

It's not like they're performing a csection on you without pain medicine.

In most 1st world countries women labor with nitrous oxide instead of epidurals. Many hospitals around here are now offering that as an option.

As much as no one wants to hear it, Medication durin/ at birth is a comfort measure, not a medical necessity.

Depending on the medical reason for refusal of the epidural, opiates may also not have been an option OR the hospital may have no protocol for using them.

It goes against the grain to say so, but no woman should rely on the fact that she can and will get pain relief during labour. There are a lot of medical reasons not to.

Isn’t this the case for any and all medical procedure and surgeries? I mean if they amputate a limb is pain relief really medically necessary?