Once upon a time there was a mom named Suzy expecting her first child. As her tummy grew, her fear of birth also grew, but she found comfort in the fact that she would get an epidural in labor and she would have a painless labor and delivery. All of her friends had an epidural and encouraged her greatly in her choice. Many said “get it as soon as you get to the hospital”, and others said “don’t be a hero, just get it as soon as the contractions start hurting”. That was her plan.
Suzy did not take a childbirth class. “What a waist of money”! she thought. “Childbirth classes are for people who want to go natural”, she foolishly told her husband when he asked if they should sign up for a series. All of her friends discouraged taking classes. They took a class at the hospital and didn’t learn anything. It was boring. It was a waist of money. Suzy believed with all of her heart they were right, so the only thing she focused on was preparing the nursery while she read some information on line about recovering, and newborn care. She was excited to meet her new baby, and as she got closer to her due date, she started looking forward to her pain-free birth.
Suzy went in for her 39 week OB appointment. Along with other normal complaints, Suzy was telling her doctor that she was starting to get itchy on her belly and her hands. Her doctor ordered some blood tests and mentioned she might have to be induced. This was great news! She was tired of being pregnant, and she was going to see her baby soon! She anxiously waited for the call, and it came shortly after lunch the next day. The doctor confirmed his suspicions and told her that she would need to come in to the hospital for an induction the following morning. Yes! That was the news she was waiting to hear! Then the doctor’s tone got a little more serious “Suzy?
“Yeah...” she said nervously
“You won’t be able to have an epidural, and if you have to have a cesarean, you will have to do it under general anesthesia."
“WHAT?” Suzy exclaimed. Panic, fear, anger, and started to set in. She felt dizzy and shaky. She sat down, and asked again. “What do you mean? I don’t understand...”
“Your platelet count is getting to low to safely get an epidural”, the doctor slowly answered - “sometimes this happens with your condition”.
Suzy was still a bit confused. “Why can’t I have an epidural, I thought everyone could get an epidural”? Her doctor explained that her platelet count was too low and that increased her risk for bleeding, particularly, bleeding into the epidural space - and sometimes that can lead to permanent paralysis. Suzy felt queasy and light headed. Then she had an idea! “Can we just schedule a cesarean instead?” Suzy was just as terrified of a cesarean as she was of giving birth naturally. She never really let her mind go "there" because it was such a terrifying thought, but now she was finding some hope and comfort in the thought that maybe she could just get it over with and see her baby sooner!
“No, Suzy, I’m afraid that isn’t the best option. With a cesarean you are at more risk of bleeding, so a vaginal birth is going to be much safer for you. Did you take any childbirth classes”? Ugh. There was that dirty word again. Suzy was irritated. “No” she said quietly. “Don’t worry”, her doctor replied, “we’ll get you through it, I’ll see you in the morning".
Suzy stayed up late that night reading as much as she could about her condition. She tried to find tips on how to have a natural labor. She fell asleep in bed with her laptop open and before she knew it the alarm clock was going off and it was time to head to the hospital.
I don’t need to go into a ton of details. Suzy had a very hard time dealing with the contractions. Pitocin induced contractions are usually harder than contractions that come on their own. She couldn’t remember half of what she read about how to cope with the pain, and the things she did remember couldn’t be used because of her limitations of movement. She was strapped to a monitor that could only reach a few feet. She screamed, she cried, she withered in pain. Her husband cried in the corner, helpless and defeated. She begged for a cesarean, and after several hours, her doctor agreed that a cesarean would take place later that evening. In the end, Suzy had a healthy baby, but the memory of her birth left her feeling deeply depressed and symptoms of post traumatic stress syndrome was rearing it’s ugly head. Eventually, Suzy became a big proponent of women being educated on epidurals. She didn’t want people to go into labor without realizing that NOT having an epidural IS a possibility, and that taking a good childbirth class, is important not matter what kind of birth you are hoping for. Suzy did go on to have 3 more children after that, and she gave birth to them all without medication - not because she had to, but because she chose to. She has come to find some healing from her first birth experience. Suzy is a survivor!
Suzy couldn’t get an epidural, and here are 7 reasons why you might not get one either:
#1 - Low Platelet Count:
This was Suzy’s situation. Low Platelet or Thrombocytopenia occurs in 7-8% of pregnancies. In a way, Suzy was a little more fortunate than some moms - she had some advance warning. That’s not the case for everyone. Some women enter the hospital in labor, and won’t find out until their labs come back after admission. Keep that in mind if you are heading to the hospital and plan to get an epidural 10 minutes after you arrive. It can take at least 30 minutes to get enough fluids in and blood work to come back before an anesthesiologist will touch you.
The most common causes of thrombocytopenia in pregnancy are as follows:
Gestational thrombocytopenia (70%)
Immune thrombocytopenic purpura (3%)
Normally, you have anywhere from 150,000 to 450,000 platelets per microliter of circulating blood.
Thrombocytopenia can be defined as platelet count less than 150,000. μ
Each hospital and/or anesthesiologist has their own comfort level on when an epidural can and cannot be used. For most, if it’s below 80,00 they will not do an epidural, others have more rigorous guidelines and platelet count will need to be above 100,000 for an epidural.
#2 - You are on medications that interfere with blood clotting.
See low platelet count. It is possible to have an epidural if the provider can take the mother off of the medications a few days before a scheduled induction.
#3 - You can't sit still enough.
This probably goes without saying, but if a person can’t sit still through the procedure, there is a chance of putting the needle where it shouldn’t go. An anesthesiologist may stop the procedure if it gets too risky. That being said, most women manage even in serious labor with heavy-duty contractions going on.
#4 - They don't have time.
You’ve probably heard that you can’t have an epidural after X centimeters. This isn’t always the case anymore. Here in the DFW metroplex, I’ve seen moms get an epidural at 9.5cm! I’ve also heard of cases where it is given during the pushing stage - but this is generally when things are going slow, not fast. There are still hospitals and anesthesiologists out there that have a rule about how late you can get an epidural, so it’s always best to talk to your provider about that in your prenatal appointment. Usually when they don’t have time it’s either because mom walked into the hospital too close to pushing time and they don’t have the time to run the IV fluid bolus and get labs back in time. They will still try to get it all done, but sometimes baby comes anyway :-) There are some hospitals that do not employ anesthesiologists around the clock, so in some cases, mom will have to wait for the anesthesiologist to get to the hospital first. Usually she can still get the epidural, but sometimes birth happens too fast! Occasionally, a smaller hospital with only one anesthesiologist means that people have to wait their turn. If a mom asks for an epidural and that anesthesiologist is in the OR, he/she may not be able to rush to your bedside until they are done. Again, it’s just a matter of timing and sometimes the timing works against us.
#5 - You have an infection at the site of needle insertion.
If you have an infection and the needle picks it up on the way in, it can give a free ride for that bacteria to your insides. This can lead to even bigger problems. Like epidural abscess. Not something you want to mess with!
#6 - Doctor can't get it into the right space.
If a patient has spine issues such as a deformity, or has had spinal surgery, an epidural can be a little harder to do for some anesthesiologists. Sometimes you can schedule a consult with an anesthesiologist during your pregnancy to discuss whether or not you are a good candidate for an epidural. Still-that doesn’t guarantee that the anesthesiologist on call that given day can do the procedure, or won’t need to try more than once to get it right. Each person will be considered on a case by case basis during labor, regardless of what you’ve been told previously.
Larger women, (those who might fall into the “morbidly obese” category), may also have trouble either getting an epidural, or getting an epidural that actually works. Placement of an epidural - or spinal needle in an obese patient can be difficult because the extra padding may obscure landmarks such as the midline and inter-vertebral space. Repeated attempts at needle insertion may be required, the failure rate is higher, and there is an increased risk of them puncturing the dural space. Using an ultrasound machine to help find the landmarks has shown to be helpful, so ask your anesthesiologist if that is an option.
Another thing to consider, is that studies have shown that morbidly obese women have an increased risk for lowered blood pressure and prolonged fetal heart deceleration's following an epidural anesthesia during labor. http://www.ncbi.nlm.nih.gov/pubmed/21864821
#7 - Mom is actively hemorrhaging.
I’m sure it stands to reason that when mom is bleeding too much, there are bigger concerns going on. The reason why an epidural is contradicted is because epidurals tend to lower blood pressure. Women who are actively bleeding also tend to have lower blood pressure and the two together might bring it down even more.
Keep in mind that each person and situation is different. Some women will still get an epidural with the listed contradictions, while others may not get an epidural for something not on the list! These situations are rare, but they do happen, and I have supported moms through these births. Thankfully, most of them knew ahead of time that an epidural may not be in their birth plan. For those who did not expect it, they were very thankful they had the support and education to get them through.
As for those who planned an epidural and it didn’t work, or it didn’t work as well as they hoped? Well, that’s a blog for another day :-)
If you are reading this because you too cannot have an epidural, you may find this short blog helpful as well: Can’t have an epidural? Lets make a gameplan!