Epidurals are a miracle technology
worksinprogress.co78 points by karakoram 3 days ago
78 points by karakoram 3 days ago
There's a very strong podcast series about the common failure of Epidurals: "The retrievals" season 2, by serial productions. I found it rather eye-opening. The series includes reporting on a conference of the Society for Obstetric Anesthesia and Perinatology (SOAP) where the professionals in this field also found it eye opening. (mostly episode 2)
I don't bring this up to say that actually Epidurals suck, just to bring attention to the fact that they can fail, and that the system has historically handled such failure really poorly, and that the system itself isn't very well aware of this issue. This isn't just opinion from some podcast, but also admitted by the professionals working within this field.
It's also something valuable to be aware of when you or your partner is planning to have an epidural, because there is real space (and even a need) for advocacy for the patient when an epidural fails and the woman giving birth is in excruciating pain.
The problem that The Retrievals deals with is epidurals failing during cesarians, which, they're quick to emphasize, is painful, open abdominal surgery. The not-so-simple solution is to convert to general anesthesia (anesthetic gas, IV propofol, etc). This isn't without its risks to the mother and the child, so there's reluctance on the part of anesthesiologists to go that route if there's other options. The result is unnecessary birth trauma.
> This isn't without its risks to the mother and the child
> The result is unnecessary birth trauma.
Not trying to be snarky, but which is it? This is definitely a situation in which having a midwife there to advocate for you is an absolute plus.
If it were as simple as waving a magic wand and fixing the epidural or bringing on the anesthetic gas, we wouldn't have this problem.
The consensus seems to be shifting more towards converting to general anesthesia after epidural failure unless there are very clear reasons not to.
The "risk to mother and child" is referring to using general anesthesia. The "unnecessary birth trauma" is referring to C-section without any anesthesia.
I was shocked to discover that if a woman gets an epidural, it stops producing oxytocin that mitigates the pain for the baby (and mom).
That sounds absolutely horrible for that little creature. Yet I am a man, so I really am not allowed to speak on the matter and I absolutely let my wife decide entirely on the matter by herself (we had absolutely no time for an epidural, my wife delivered both kids way too fast)
I looked for a source for this, and found the opposite:
> Newborn oxytocin levels were higher in the umbilical artery vs. umbilical vein, and both were higher than maternal plasma levels, implying substantial fetal oxytocin production in labour. Newborn oxytocin levels were not further elevated following maternal intrapartum synthetic oxytocin, suggesting that synthetic oxytocin at clinical doses does not cross from mother to fetus.
In other words, the fetus makes its own oxytocin during labor. It does not come from the mother.
[1] https://link.springer.com/article/10.1186/s12884-022-05221-w
Male scheduled for my 3rd epidural with steroids next week for on-going spinal stenosis, relieves pain for a few days, then back to pain.
Will go for minimally invasive micro laminectomy next, tired of treating symptoms and not the root cause.
In that procedure surgeon will remove parts of lower vertebrae that is pinching the nerve bundle, nerves that progress down each leg.
Success rates of better than 70%, it's a gamble. But willing to accept that rather than end up on addictive pain pills for life.
3 to 6 months recovery period before active lifestyle again, cannot risk disturbing the "fix". Giving up flip turns in lap swimming for quite a while. Supplemental covers the other 20% that medicare won't pay.
Cash paying patients suffer $35k to $45 K for the procedure.
Medicare pony's up only about $6,500, which the surgeon must accept, no extra cash changes hands.
Supplemental covers the 20% that medicare will not pay.
I understand everyone has different beliefs, and personally, I fall extremely short of what I should be, but I just took some time to pray for you and your procedure. I really hope the root cause is fully resolved.
[flagged]
Instead of saying words to one of the many tens of thousands of religious comments that would presumably annoy you, you could also help research on this topic instead of dumping on someone trying to be encouraging who already hedged that not everyone agrees with them.
The maker of the universe is not "one of many tens of thousands of gods". You proclaiming that your house has no architect because you read about ancient kids playing with block buildings changes nothing about the architect of your house.
In computer terms, you conflate by ref with by val. An idol is by val. The maker of the universe is spoken of by ref, and not by val.
Learn the difference.
(While it's clear you've done a ton of your own research for your own case.)
Steve Kerr's advice after his own back surgery complications (albeit microdiscectomy, not a laminectomy) make me hesitant:
"If you're listening out there, if you have a back problem, stay away from surgery... Rehab, rehab, rehab. Don't let anybody get in there."
The heuristic I found when researching this a few years ago was slightly more nuanced than your quote: back surgery is very likely the wrong solution for back pain.
But if you have nerve problems caused by an issue with your spine, you probably want to address them before they become worse or irreversible, and back surgery may end up being the only option.
I helped a friend through a microdiscectomy, and it could not have gone better. Laparoscopic procedure, short recovery, lifechanging reduction in symptoms. The biggest hurdle was that their insurance required PT/rehab prior to authorization, even though all the experts involved agreed that it would not help.
This kind of comment is only marginally better than "well, I asked ChatGPT and...."
You acknowledge the parent commenter knows more than you, but you decide it's somehow helpful to post contradictory information anyway sourced from someone else who also likely knows more than you.
You don't have to listen to Steve Kerr. Every back doctor I have seen has said the same thing - surgery is the absolute last resort. I was fortunate that the epidurals worked for me, because it was the worst pain I have ever felt.
It's a good idea to ask a few AIs to get extra feedback. They may be wrong, your doctor may be wrong -- it is better to have a set of inputs and, to some point, check it against sources.
My mother had this surgery and advised me to never have it done due to complications
Go for surgery if you have neurological symptoms (loss of sensation, motor function, etc). If its pain, try your best to avoid surgery and find the right physiotherapist to help you be pain free. Spine surgery is risky and there is a risk of cascading failures.
Don't completely trust any anesthesiologist (pain management) or neurosurgeon (for surgery) or chiropractor or random folks advice to do yoga/stretch. Spend quite a bit of time understanding the anatomy, read up on everything and maybe you will find the right set of exercises to help relieve pain. Troubleshooting disk/spine/nerve issues is very hard and most doctors don't have any time to investigate it deeply. They just look at MRI. There are lots of people with the same problems showing up on MRI, but they are pain free.
why "not" yoga/stretch ? I understand it may not be the right thing for every kind of pain but the way it is usually presented (your body needs movement) sounds convincing. (I don't practice yoga but taichi)
I don't understand the downvotes. If you have any counterpoints, please do share so I can learn instead of downvoting.
I have to cautiously agree with you, with the caveat that many physios don't seem to know what they're doing either and the effectiveness of therapy can differ wildly based on which therapist and what regimen they use. Speaking as someone with a herniated disc that went through a discectomy which re-herniated immediately following surgery. Frankly I've only just now started getting relief by reducing the amount of weight pushing on the disc by way of treatment with semaglutide. Could've saved myself thousands of dollars in medical costs and rehab if I'd just done this a year ago.
> Speaking as someone with a herniated disc that went through a discectomy which re-herniated immediately following surgery.
Sorry to hear about re-herniation. Thats what I am concerned about. I have multiple disc herniations, one with cauda equina. Multiple neurosurgeons have recommended surgery, but each is going to do a different procedure. I understood as they don't fully understand whats the root cause, everyone wants to do the procedure they are comfortable with and what they've been doing. One wants to cut the disc, another remove lamina, another fusion and something else. I decided its not worth taking the risk when they don't know what they are doing. There are so many reports of failed back syndrome, revision surgeries, cascading failures (because it increases pressure on adjacent discs).
> with the caveat that many physios don't seem to know what they're doing either
Yes, this is true of nearly any profession. We just have to spend significant time researching and troubleshooting with an engineering mindset.
Honestly surgeons should be paid hourly like technicians. $800/hr or something like that. For a 2 hour procedure, $1600. Another $5k for facility and support staff. Looks like medicare is on point...
I'm with you until I remember how expensive medical school plus internship is in the US. If doctors cannot pay back their student loans, it doesn't matter. The majority of folks in medical school have family that can support them now - not fixing education will make this even worse.
Don't get me wrong. I support state-sponsored health care, especially after moving from the US to Norway over a decade ago. Just the peace of mind not having to worry so much about financial ruin because of health issues relieves so much stress - even stress related to just keeping yourself healthy is less (If I get hurt while jogging, it isn't a big issue, for example) But fixing the US system is bigger than just payments or insurance for all. Gotta fix things like education costs, the burden of unpaid internships, and things like that, too. I wish it weren't such a complicated problem and I wish there were the political desire to do such a thing.
Medical professionals in the US make multiples of what the same professionals make in Europe.
This gets said a lot and it kind of irks me. (I am a physician.)
US software devs also make 2x what their European colleagues do, but that never gets called out as bloat. Plus US software devs make that 2x pay without taking our additional loans for medical school at the rate of $75k per year or doing years of low pay residency where their salary doesn’t give them the means to pay off those loans.
> US software devs also make 2x what their European colleagues do, but that never gets called out as bloat.
Of course it does. And it gets acted on. Every major corporation in America has explored or implemented moving to European or other foreign developers to save costs.
Developers also don’t have the advantage of a trade group that prevents this practice, requires particular education or limits the number of people allowed to get that education.
Don't forget the insurance, plus the hospital has costs that must be paid for too. A surgery with _just_ the surgeon and no support staff isn't one I'd want to be in.
(Not in the medical field at all)
But in Europe the state also tends to cover their schooling to become a doctor.
And the best of the best of medical students the world over compete to enter the US market. Being US board certified garners the highest pay even outside the US (eg GCC).
It’s kind of like our industry - the higher comp is a big reason behind how the US attracts talent from all over the world.
Just wanna point out that this sort of statement only really applies to the anglosphere. As in "medical students the world over can generally only speak english and their native language, so they can either apply for studies in their home country or an english speaking country, and some try to go to the US".
Not every country is in contention, as even if, for example, Hungary has the best medicine program, very few people are gonna learn Hungarian just to attend the university. The same argument applies for every country which requires a non-english language for admission.
This is not the case in Europe. You would not gain anything by being a doctor from the US vs the local ones. You may even be in a worse position due to many differences between the US and the host country.
Good surgeons are a bit like major airline pilots. They have more pricing power than you think.
I've heard a few times now that giving birth while lying on the back is a relatively modern invention and that for most of history women adopted squatting or leaning forward positions.[1] And that the back position is actually much more painful. How much does laying on the back increase the pain to the point where an epidural is necessary? Is it still necessary in the other positions?
disclaimer: I know nothing about this
[1] https://www.bbc.com/future/article/20260401-women-were-never...
Anecdotally from personal experience (gave birth to one child on back, the other in a squatting position, didn't have an epidural for either), the pain didn't depend on position - very painful both times! But pushing felt much much easier squatting than on my back.
The hospital only had two rooms suitably equipped for giving birth in a squatting position, so I was lucky to get one second time.
When you've been given an epidural, you are generally required to be in a bed. (This doesn't answer your question, but I think it is relevant.)
My wife works at a leading private maternity hospital in India. I can’t yet report from personal experience, but my wife says that epidurals are normal procedure, and per the hospital’s published statistics, about 90% choosing to give birth propped up or squatting (this figure excludes C-sections, water births, and complicated cases), which implies not being in a bed for at least the last part.
Here in Argentina the nurses discourage you to seek it, then they blame the anesthesiologist is not available. We have had 2 with cesarian and one friend was in so much pain that she had to ask for a cesarian too.
It was surprising to see incidence of death by cesarean is almost 13 per 100k. It is commonly thought as the safest way and half of all births in my country are via cesarean.
I wonder how much of that is selection bias? In my (admittedly limited) experiences around the labor and delivery process, c-sections were (apart from when requested) advised for high-risk pregnancies and as a recourse for something having gone wrong in the L/D process. One could reasonably expect that both of those situations would indicate a higher risk for mortality from surgery.
Note that per Wikipedia [0], death by abdominal surgery in general in High-HDI countries is on the order of 100-1000/100k.
There's selection bias. High risk deliveries tend to start at or convert to cesarian at the first sign of trouble.
In what country do you live? I've had children in two European countries, in both it was common knowledge that natural birth is safer then cesarean and doctors/hospital strongly prefer it.
> doctors/hospital strongly prefer it.
Seems to depend a lot on the hospital. We (partner is pregnant with a high risk pregnancy) were at a level 1 prenatal care center in Germany a few weeks ago where they very much insisted that in her and the child's condition, a c-section is pretty much her only option.
We're now in a different, also level 1, prenatal care center, also in Germany (though a different state), where the prevailing medical opinion is "natural birth should work perfectly fine for you. We're not ruling out a c-section in case things go sideways, but natural birth is very much our preferred option in your case."
The first center seems to be quite keen on using as many cases as possible for training their staff in c-sections, even where it's not strictly necessary/beneficial. At least that's what we've heard from other parents in similar situations.
To add to this, C-section rates seem to be significantly higher in private hospitals, when compared to public hospitals.
I wonder to what degree this is a "if you are a hammer, everything looks like a nail" type of thing.
The first place might have a strong surgical team and might be inclined to solve everything via surgery?
I think this is going to depend strongly on population. Average age of the mother, width of the pelvic canal, and similar are going to vary widely with culture, race and country.
Its hard to measure, but for the UK at least, and depending where you are, you try natural, then if shit goes wrong you graduate to ceasarian.
So it would be interesting to see the elective vs crash ceasarian rate.
We had 3 kids, one with an epidural and induced labor and the other 2 were natural child birth, no medication at all, and my wife much preferred the natural child birth -- all of them at at a hospital "birthing center", with a five minute walk to an OR if needed. She was more present emotionally at birth, we were able to walk out of the hospital with our baby a few hours later. She was practically bedridden for a week after the induced labor with the epidural.
Obviously, I'm only a spectator, but the overall experience seemed way less traumatic and stressful for her with the natural child birth, working with midwives and nurses rather than doctors.
Interesting to find out that the contents of epidurals are not standardized across facilities. If that is the case, then how can one definitely opine on the safety of them when the contents are locally designed cocktails?
It's not as if people are pushing random drugs into epidurals. There's a small number of drugs that are commonly used and the differences come down to selecting the classes of drugs to be used, the particular drugs from those classes, and the dosing. There's no one right answer. In other words, it's just like the rest of anesthesia.
> how can one definitely opine on the safety of them
Because the statistics still include all those variations. The variations are also not that huge, and are also independently studied.
You might as well ask how we can talk about the risk/safety of general anesthesia, given that different hospitals and even different anesthesiologists use different drugs.
... Except when they injure your spine, like with one of my friends. I'm not sure why women choose painless childbirth, which is not only potentially bad for them, but for their newborns as well. My wife gave birth to 3 children, two in the US, and doctors were shocked she didn't want them. Yes, it hurts. The moment your child is born, all pain is gone, and you're in the most beautiful state ever, and this creates even a stronger bond, knowing what you had to go through to bring a child to life! Men, women - we're all weaklings today. When I think about our ancestors and the sword-and-spear bloodbath battles they fought in to protect their families, we don't have such men and women anymore! Pain is an essential part of life. Chronic pain is a different story, of course.
There's a lot of people out there who blame their epidurals for lower back pain and the like, but the evidence for causality is not there.
Suffering is not a virtue
It surely is. Ascetism and stoicism are extinct virtues, maybe venerated only in Eastern Orthodox Christianity. Many of our holy fathers have suffered terrible torture and death, but they even welcomed it. That's why Orthodoxy is so hard to grasp in the West, where people damage their livers just to tame their headache a bit, let's say.
It’s funny, because Paul criticised such thought in Colossians 2:23:
> These have indeed an appearance of wisdom in promoting rigour of devotion and self-abasement and severity to the body, but they are of no value in checking the indulgence of the flesh.
Meaning: sure, looks good, but doesn’t actually help if the suffering itself is your goal.
(Notwithstanding this, Acts 5:41. A lot, in such topics, depends on exactly how you present things.)
I've woken up from surgery with an epidural that had a leak. That wasn't fun.
It made it emotionally difficult to get surgery again.
Epidurals apparently also reduce the likelihood of birthgasm
[flagged]
[flagged]
HARD disagree. Watch “the business of being born”. We’ve turned a fairly routine extremely biologically conserved process into this insanely traumatic experience.
Husband of a UK doctor here.
first, childbirth is fucking dangerous. Its also unnecessarily painful. In terms of risk[1], the epidural is not the thing thats going to cause "morbidity", its the baby coming out breech or massive internal bleeding.
A non insignificant number of women literally tear themselves a new arsehole when delivering a baby. Yes elective caesarians can carry higher risks, but also might be required to actually deliver a live baby, or save the mother.
THe problem for the statisics is that there is a difference between elective caesarians and emergency once. If you group them together, then you're going to get a higher mortality/morbidity rate, because there’s a reason why it was an emergency
Personally I have no fucking clue why people wouldn't want an epidural. My wife didn't want one the second time because "she wanted to get home quicker" (by a fucking day) it turns out by her own words: "it was way way more painful without the epidural" bear in mind shes a fucking doctor, and a paediatric one at that.
[1] Women of African origin in the UK have worse outcomes in child birth, partly because of the lower uptake in pain relief.
extremely biologically conserved process
This seems just plain wrong. It is not at all extremely biologically conserved.
Pregnancy and birth varies wildly across species. Not conserved. For primates, it's got problems; in humans, pregnancy is an absolute mess. The birth itself is historically one of the most dangerous things a woman can do, and remains not exactly a walk in the park even with the best of modern interventions.
I rather think the problem is that births are inherently traumatic (a whole-ass little human coming out of your crotch isn't exactly all fun and games; there's a reason similar imagery is a common trope in horror movies), and we haven't put nearly enough effort into making them less so.
Birth in humans is not a "extremely biologically conserved process". Women bodies are not ready for the size of head of the baby.
Compare this to cows or horses - where the baby is of sizeable size, but goes statistically smoothly.
Why don't you go ahead and give birth then, tell us all about your experience.